
G)fiyright N l 



4&. 



COFflUGHT DEPOSIT. 



TREATISE 

ON 



FRACTURES 

IN 

GENERAL, INDUSTRIAL, AND 
MILITARY PRACTICE 



BY 

JOHN B. ROBERTS, A.M., M.D., F.A.C.S. 

emeritus professor of surgery in university of pennsylvania graduate school of 

medicine; president of the American surgical association; 

membre de la societe internationale de chirurgie 

AND 

JAMES A. KELLY, A.M., M.D. 

associate professor of surgery in university of pennsylvania graduate school of 

medicine; attending surgeon to st. Joseph's, st. mary's, 

st. timothy's and misericordia hospitals 



SECOND EDITION 

REVISED AND ENTIRELY RESET 



WITH 1081 ILLUSTRATIONS: 
RADIOGRAMS, DRAWINGS AND PHOTOGRAPHS 




PHILADELPHIA & LONDON 

J. B. LIPPINCOTT COMPANY 








\ 



fr'l 



V 



COPYRIGHT, I9l6, BY J. B. LIPPINCOTT 0OMPANY 
COPYRIGHT, 192 1, BY J. B. LIPPINCOTT COMPANY 



Electrotyped and Printed by J. B. Lippincoit Company 
The Washington Square Press, Philadelphia, U. S. A. 



CU617452 



M 24 m\ 






PREFACE TO SECOND EDITION 

Many opinions on surgical therapeutics have been modified by the 
1 experiences and great clinical opportunities of the World War. 

The treatment of gunshot wounds of bones has been revolutionized 
therebv, because a distinction has been made between contaminated and 
infected open fractures. Lucas-Championniere's dogma that early mobili- 
" zation and gentle massage are of value in restoring function and contour 
in fractures of shafts and joint-ends of bones has been accepted. Lane's 
insistence that closed fractures need operative fixation with steel plates, 
as a usual routine, has been found to be an untenable creed. Treatment 
of fractures of the femur and of the tibia by suspension, long ago advo- 
cated by N. R. Smith, Hewson and Hodgen in this country, and by others 
in Europe, has been reinstated in general favor. Critical, intelligent, and 
frequent examination of fractures, instead of a too absolute reliance on 
radiographic interpretations by inexperienced laboratory workers, has 
become an orthodox requirement. These are a few of the by-products of 
war surgery brought from the battlefields of Europe. 

Another agency forcing a revision of old methods in the treatment 
of broken bones is the advent in the United States of workmen's compen- 
sation laws. The payment, by industrial plants and firms, of money for 
hospital care and surgical treatment of injured employes, has deepened 
the sense of responsibility in hospital trustees, surgeons and physicians. 

In response to these determining factors, there has been an endeavor 
to make, in this second edition, a volume of value to all those who 
treat fractures. 

The reader, whether engaged in private, in industrial or in military 
surgery, will find that the text has been thoroughly revised, particular 
attention given to differential diagnosis and many valuable illustra- 
tions added. 

A general view of the contents of the book will be obtained from 
the following summary of treatment: 

i. The treatment of broken flat bones consists in great part of atten- 
tion to associated injuries of the contents of cranium, thorax, abdomen 
or pelvis. 

2. In fractures of the shafts of long bones, with absence of impaction 
or entanglement, overriding often may be overcome by means of gentle 
massage, or moderate traction, aided by rest in bed and anodyne remedies 
to relieve pain and quiet the patient's nervous system. This statement 
applies with great force to fractures at upper end of humerus and of femur. 

3. Radiographic study, to determine the degree of success obtained 



iv PEEFACE 

by efforts to reconstruct anatomical contour, is not infrequently deceptive. 
This is due to variations in the relative position of the Crookes tube, 
the fracture and the photographic plate ; or to faulty interpretation of the 
skiagraphic negatives. 

4. Reduction, often under general anaesthesia, is an essential in frac- 
tures, especially in impacted fractures. The exact direction of the reduc- 
ing force to be applied by the surgeon's hands may be indicated by 
radiographic examination. 

5. Fractures of the maxilla and mandible frequently require that the 
surgeon have associated with him a competent dentist to prevent faulty 
occlusion of the teeth after union of the fracture. 

6. The doctor should remember that however desirable perfection of 
anatomical contour may be, a functional restoration of the limb, as a whole, 
is of major importance. Obtain both, if practicable, but keep the patient 
alive and give the preference to good function rather than good looks, if 
either one has to be sacrificed. 

7. The majority of closed fractures of long bones may be cured with 
good function and good anatomical result, without exposing the bone 
by operation. Some open fractures of these bones, if kept aseptic, may 
be cured without exposing the bone by operation. 

8. A moderate proportion of closed fractures of tubular bones will 
need operative exposure to correct malposition of fragments, and may 
require direct fixation. 

9. Many open fractures, especially gunshot injuries, will require 
operation to convert contaminated fractures into aseptic fractures, and 
to permit primary closure of the wounds. Some of these open fractures 
will also need readjustment and possibly direct fixation of fragments. 

10. Conversion of contaminated open fractures into aseptic fractures 
should be done within the first eight or ten hours, by removal of foreign 
bodies and excision of debatable soft parts. The wounds should then be 
closed by primary suture and the bones given external rigid support : and 
the patient kept under careful surgical observation for advent of sepsis. 

11. Closed fractures, needing exposure of bone for readjustment of 
fragments, will probably escape operative sepsis more frequently if opera- 
tion is delayed about seven days after injury. 

12.. Comminution of bone in closed fractures does not add much to 
the severity of the injury, but it requires that the accuracy of coaptation 
and of external support receive vigilant attention. 

13. Comminuted open fractures, if kept aseptic or early rendered 
aseptic, do well, because the small fragments furnish many centres of 
callus deposition. 

14. Nearly all closed fractures, and many open ones of the upper 
limb, may be successfully treated as to functional ability and anatomical 
integrity by means of ambulatory dressings. 



PREFACE v 

15. Nearly all fractures of the lower extremity, whether open or 
closed, do better when treated in bed with suspension of the limb and 
more or less continuous traction. Surgeons, however, are apt to forget 
that increased overriding of fragments is often caused by muscular spasm, 
due to pain or insufficient repose of mind and limb. Continuous moderate 
traction, with lateral support at seat of fracture, with opiates and bro- 
mides internally, may be better than great addition to traction weights. 

16. An exception to the rule of treating fractures of the lower limb in 
bed may occur in fractures of the fibula and of bones of the foot. 

17. Most fractures of the femur, and a considerable number of 
the tibia, must have traction added to suspension of the external fixa- 
tion apparatus. 

18. A few fractures of the upper limb, closed and open, require suspen- 
sion with traction. This is particularly true in fractures near the upper 
end of the humerus, and is more frequently needed for infected than 
closed fractures in this site. 

19. Fixation by external splinting is best given to the upper limb by 
using the thorax as a splint for fractures of upper part of the humerus, 
and some form of plastic material moulded to the surface for fractures 
of lower part and for the forearm. Encircling the arm or forearm by 
gypsum encasements is dangerous in early stages of the treatment. Frac- 
tures of the internal condyle often do well with full flexion of the elbow. 

20. When suspension and traction are required for upper-limb frac- 
tures, the patient should be kept in bed for a time. Traction and splinting 
should usually be obtained with steel rods similar in form to the splints 
and braces used in fractures of the lower limb or with a modified Buck's 
traction apparatus. 

21. The suspension and traction so valuable in fractures of the femur 
may best be obtained with the suspended N. R. Smith or Hodgen anterior 
heavy wire splint, a modified Thomas splint, or with traction by the 
Buck's traction method, with or without suspension, or by use of the 
Bradford frame. 

22. The Thomas splint is probably the best of these methods in adults 
with great overriding of the fragments. It is particularly valuable when 
the patient must be subjected to transportation. The open ring Thomas 
splint and the one with movable footpiece are improvements over the 
earliest forms. 

23. The joints, muscles and skin in fractures should be given atten- 
tion from beginning to end of treatment by mobilization and gentle mas- 
sage, if the best results are to be obtained. 

24. Joint fractures should not be kept immobile longer than one or 
two days. Careful passive and active movements usually should be allowed 
within the first few days, and frequently repeated during the course 
of treatment. 



VI 



PBEFACE 



25. It is a common practice to permit weight-bearing on fractures of 
the lower extremity too soon. Secondary deformity is frequently caused 
by this error. Crutches, braces and other devices often should be used 
after union to prevent such deformities. 

26. No special form of splint or apparatus may be substituted with 
safety for the requisite knowledge of anatomy, pathology and mechanics. 
It is acquaintance with these subjects which constitutes a surgical grasp 
of the particular fracture needing intelligent care. These propositions are 
the essence of the teaching which it is hoped this volume will impart. 

Thanks are due to Dr. Wm, H. L. Hale for much labor devoted to 
proof reading and preparing index. 

J. B. R. 
J. A. K. 
February 21, 1921. 



PREFACE TO FIRST EDITION 

The object of this book is to supply student and medical practitioner 
with a clear, concise, and systematic presentation of the subject 
of fractures. 

In the following pages, a careful classification of the varieties of 
fracture occurring in each bone is given, together with statistics, symp- 
tomatology, diagnosis, prognosis and treatment. The varieties of fracture 
are shown by well-selected radiograms, the displacement of fragments 
is illustrated by accurate drawings, and when possible the methods of 
reduction and the application of retentive apparatus are presented 
by photographs. 

The universal use of the Rontgen ray as a means of accurate diag- 
nosis has brought about greater success in the recognition of fractures 
and has shown that many received methods of treatment are faulty or 
imperfectly understood. As a result, many fractures have been operated 
upon in which good anatomical and functional results could have been 
obtained by more conservative measures. 

The purpose of the authors is to present a lucid view of the subject 
in the light of recent discoveries, to point out an accurate scientific 
procedure, whether operative or otherwise, according to the character 
of individual injuries, and to urge the general practitioner, as well as 
the surgical specialist, to the study of methods, operative or non-operative, 
with augury of propitious result. 

The authors are indebted to Drs. M. B. Miller, J. H. Jopson, G. G. 
Davis, G. P. Muller, J. H. Hutchinson, J. M. Spellissy, L. J. Hammond, 
J. T. Rugh, E. R. Kirby, J. H. Ross, J. A. Boger, A. C. Wood, H. S. 
Carmany, A. Hewson, O. A. Rath, J. Chalmers Da Costa, C. F. Nassau, 
M. M. Franklin, J. F. X. Jones, A. A. Sender, F. C. Hutton, and M. F. 
Percival, for many roentgenograms. 

The photographs of specimens, patients, dressings, and copies of 
skiagrams were made by Mr. Meyer S. Lentz, the original drawings 
by Mr. Erwin F. Faber, to both of whom the authors are grateful for 
skill, patience, and untiring energy. 

vii 



viii PREFACE 

In all instances an endeavor has been made to give proper credit in 
the text and illustrations to the work of other writers. 

Finally they wish to thank the publishers for many helpful suggestions 
and active cooperation in the presentation of this volume to the medical 
profession in such an attractive form. 

John B. Roberts 
James A. Kelly 

Philadelphia, January, 1916. 



CONTENTS 

CHAPTER PAGE 

I. General Considerations i 

Causes, Varieties, Symptoms, Diagnosis, Repair, Complications, 
Anaemic Myositis, Prognos : s. 

II. Epiphyseal Separations 48 

Ossification of Bones, Union of Epiphyses, Causes of Separation, 
Diagnosis, Treatment. 

III. Treatment of Fractures ••.•••. 6l 

General Considerations, Temporary Immobilization, Reduction, Reten- 
tion of Fragments, Rules for Dressings, Splints, Gypsum Encasements, 
Methods of Traction, Mobility and Massage; Functional Treatment, 
Ambulatory Treatment. 

IV. Treatment of Open and Infected Fractures 88 

Avoidance of Infection, Gunshot Fractures, Debridement, Carrel- 
Dakin Instillation, Closure, Delayed Closure, Rules for Closure, Direct 
Fixation. 

V. The Operative Treatment of Closed Fractures 97 

Indications for Operative Treatment, Contraindications, Methods of 
Direct Fixation, Committee of British Medical Association's Findings, 
Committee of American Surgical Association's Report. 

VI. Incomplete Union and Mal-Union of Fractures 130 

Varieties, Pathology, Treatment. 

VII. Fractures of the Cranium 139 

Anatomy, Varieties, Brain Complications, Differential Diagnosis, Local- 
ization, Methods of Trephining, Summary of Treatment. 

VIII. Fractures of the Bones of the Face 194 

Fractures of Nasal Bones, Complications, Treatment of Recent and 
Old Fractures. 

IX. Fractures of the Malar and Maxillary Bones 202 

Fractures of the Malar Bone, Treatment, Fractures of Maxilla, 
Pathology, Symptoms, Diagnosis, Treatment. 

X. Fractures of the Mandible 210 

Varieties, Symptoms, Complications, Treatment, Surgical and Dental, 
Summary of Treatment. 

XI. Fractures of Hyoid Bone and Cartilages of Larynx and Trachea 229 

Fractures of Hyoid Bone, Treatment. Fractures of Cartilages of Larynx 
and Trachea, Pathology and Treatment. 

XII. Fractures of the Vertebrae 234 

Anatomy, Varieties, Fracture Dislocations, Symptoms, Localization. 
Treatment, Medical and Operative. Summary of Operative Treatment. 

XIII. Fractures of the Sternum, the Ribs and the Costal Cartilages. . . . 272 

Fractures of Sternum, Fractures of Ribs, Complications, Treatment, 
Fractures of Costal Cartilages, Treatment. 

XIV. Fractures of the Clavicle 286 

Varieties, Symptoms, Complications, Treatment, Summary of Treat- 
ment. 

XV. Fractures of the Scapula 303 

Anatomy, Varieties, Symptoms, Diagnosis, Treatment, Summary of 
Treatment. 

ix 



X 



CONTEXTS 



CHAPTER PAGE 

XVI. Fractures of the Humerus 316 

Anatomy, Fractures of Upper End, Epiphyseal Separations, Fractures 
of Shaft, Fractures of Lower End, Voikmann's Ischasmic Contracture, 
Complications, Symptoms, Treatment, Summary of Treatment. 

XVII. Fractures of the Radius and Ulna 387 

Anatomy, Combined Fractures of Radius and Ulna, Treatment; 
Isolated Fractures of Ulna, Isolated Fractures of Radius, Symptoms, 
Treatment of Fractures of Radius and Ulna, Condensed Summary of 
Treatment. 

XVIII. Fractures of the Carpal Boxes 462 

Anatomy, Symptoms, Complications, Treatment. 

XIX. Fractures of the Metacarpal Boxes axd Phalanges 467 

Anatomy, Fractures of Metacarpal Bones, Symptoms, Treatment; 
Fractures of Phalanges, Symptoms, Diagnosis, Treatment. 

XX. Fractures of the Pelvis 481 

Anatomy, Varieties, Separation of Pubes and Synchondroses, Symp- 
toms, Fractures of Ilium, Fractures of Ischium, "Fractures of Coccyx, 
Complications, Treatment. 

XXI. Fractures of the Femur 505 

Anatomy, Fractures of Upper End, Symptoms, Diagnosis, Treatment, 
Operative Treatment. 

XXII. Fractures of the Shaft of the Femur 544 

Varieties, Complications, Symptoms, Diagnosis, Treatment; Fractures 
of Lower End; Varieties, Symptoms, Diagnosis, Treatment; Summary 
of Treatment of Fractures of Femur. 

XXIII. Fractures of the Patella 587 

Anatomy, Varieties, Symptoms, Diagnosis, Xon-operative and Opera- 
tive Treatment. 

XXIV. Fractures of the Tibia axd Fibula 606 

Anatomy, Fractures of Upper Ends of Tibia and Fibula, Varieties, 
Symptoms, Diagnosis, Treatment. 

XXV. Fractures of the Shafts of Tibia and Fibula 622 

Varieties, Symptoms, Diagnosis, Treatment. 

XXVI. Fractures of the Lower Exds of Tibia axd Fibula 641 

Supra-Malleolar Fractures, Symptoms, Treatment; Malleolar Frac- 
tures, Symptoms, Treatment, Summary of Treatment of Fractures of 
the Tibia. 

XXVII. Fractures of the Tarsal Boxes 665 

Anatomy, Symptoms, Diagnosis, Treatment. 

XXVIII. Fractures of the Metatarsal Boxes axd Phalanges 688 

Anatomy, Symptoms, Diagnosis, Treatment. 

XXIX. Fractures of the Small Sesamoid Bones 697 

Anatomy, Varieties, Diagnosis, Treatment. 

XXX. Obstetric Fractures 704 

Varieties, Birth Fractures, Intrauterine Fractures, Symptoms and 
Treatment of Cranial Fractures, of Fractures of Clavicle and of Bones 
of Extremities. 

XXXI. Industrial and War Fractures. 713 

Definitions, Similarity of Industrial and War Fractures, Characteristics 
of Bullet Wounds of Bone, Penetrating and Perforating Fractures, 
Shell and Shrapnel Wounds, Fractures Caused by Machinery, Railroad 
Fractures, Symptoms, Complications, Contamination, Infection, Joint 
Fractures, Transportation, Prognosis, Treatment, Debridement, Rules 
for Treating War Fractures, Open Fractures in Industry and in War. 
Fixation, Necrosis, Non-union. 



TREATISE ON FRACTURES 



CHAPTER I 

GENERAL CONSIDERATIONS 

Definitions. — A fracture is a sudden separation of osseous fibres due 
to injury ; in a general way it refers to the breaking of a bone or cartilage. 
It is applied somewhat incorrectly to a traumatic separation of an epiphysis 
from its diaphysis, though that lesion is properly called a diastasis. 

A dislocation or luxation is the sudden displacement of the articular 
surfaces of the adjoining bones from their normal relation. The term 
is also used to describe the displacement of an articular or intra-articular 
fibrocartilage from its normal relations. A dislocation is complete when 
the normal articular surfaces of the bone involved are entirely displaced; 
incomplete when the articular surfaces of the bone involved still retain par- 
tial contact. The latter condition is more properly termed a subluxation. 

A sprain or distortion may be described as an injury to a joint or 
the structures in proximity to a joint, in which the joint motions have 
been forcibly carried beyond normal physiological limits. Sprains are 
usually the result of indirect violence, although they may be produced 
by muscular action alone. The force would probably result in a fracture 
or dislocation if the violence were greater. The injury generally con- 
sists in partial or minute tearing of portions of ligaments, tendons, or 
fascias, or the bruising of the articular cartilages. 

A sprain-fracture is the partial or complete separation of a small 
portion of a bone near a joint to which a tendon or ligament is attached, 
as a result of sudden violence acting upon the tendon or ligament involved. 

Statistics. — Examination of statistics showing the liability of individ- 
ual bones to fracture proves that, as a rule, such statistics are incomplete 
as to classification or that the exact site of fractures of individual bones 
is not given. Another source of error is the fact that many fractures are 
omitted entirely, some are diagnosed as subluxations, and others as 
sprains. These defects cause the average statistics to be worthless. 

The combined statistics of Bruns, Chudowsky, Immelmann and those 
of Plagemann are, however, of considerable value. The records of 
Plagemann from the Rostock clinic are probably among the most accurate 
that have been published. 

Relationship of Fractures to Age, Sex and Season. — The influence 
of age upon the production of fractures is shown by Plagemann, both 

l 



2 TREATISE OX FRACTURES 

relative to the periods of life in which fractures are most frequently seen, 
and regarding the types of fracture which are most frequent at certain 
ages. In the first and second decades the most frequent fractures are 
the incomplete, the subperiosteal and epiphyseal separations. The bones 
most frequently involved are the clavicle, the lower end of the humerus, 
and the lower end of the radius. During the third, fourth, and fifth 
decades, the fractures most frequently met are those from an occupational 
cause and those from direct violence ; the bones most frequently affected 
are those of the leg, femur, humerus and skull. During the sixth and 
seventh decades other influences are at w T ork. In this period the bones 
are more brittle, the muscular tone of the body diminished, the special 
senses not so acute ; and as a result the most frequent fractures occur at 
the upper end of the femur, the upper end of the humerus, and the lower 
end of the radius. It may be stated that, as a general rule, fractures 
occur in the greatest number during the second, third, and fourth 
decades of life. 

Fractures are apparently more frequently seen in men than in women. 
They are said to occur in the proportion of about 4 to 1. This dispropor- 
tion is due to the more active life of the male at all ages, to the occupations 
assumed by the male, and to the fact that men spend so much more 
time out of doors. During the third, fourth, and fifth decades fractures 
occur among men six or seven times more frequently than in women. In 
infancy and old age the proportion of fractures occurring in the two sexes 
is about equal. In old age fractures are a little more frequent in the 
female, and are most often fractures of the upper end of the femur. 

The influence of season in the occurrence of fractures is shown in 
the frequency of fractures seen in the summer season as compared with 
the winter season. This is due entirely to the fact that we are more 
active, spend more time out of doors, and that the various building trades 
and all business, in fact, are carried on more actively in the summer 
season. The occurrence of ice and snow in winter may perhaps modify 
these conclusions in some places. 

Etiology of Fractures. — For the production of a fracture certain etio- 
logical factors must be present. These may be divided into ( 1 ) predis- 
posing causes, and (2) the exciting or determining causes. Fractures 
may be divided into (1) traumatic and (2) pathologic fractures. 

Predisposing Causes. — Certain bones are predisposed to fracture 
on account of their exposed position, shape, their function as levers, or 
the small proportion of osseous tissue in their composition. Other bones 
are less liable to fracture owing to their unexposed position, their mobil- 
ity, and the protection afforded by overlying muscles. Other factors are 
the elastic and yielding character of bones in infancy and adolescence; 
and the brittle character of the bones in the aged, from senile atrophy and 
thinning of the cortex. 

A predisposing factor of diastasis, or epiphyseal rupture, in early 



GEXEKAL CONSIDERATIONS 3 

age is the presence of the epiphyseal cartilages; epiphyseal separations 
occur only at this period of life. 

Exciting Causes of Fracture. — The exciting causes of fracture 
are (i) external violence, and (2) muscular action. 

Fractures by External Violence. — These may be divided by the 
mechanical modes of their production, and by the clinical difference, into 
two classes — fractures by direct violence and fractures by indirect 
violence. In fractures by direct violence the bone is broken immediately 
beneath the site of impact of the fracturing force. In injury by indirect 
violence the fracture does not occur at the site of the blow, but at a point 
distant. Fractures by direct violence may be complicated by extensive 
injury to the overlying soft parts, and secondary sloughing of tissues; 
or by the production of a wound leading to the seat of break in the bone, 
thus constituting a so-called open or compound fracture. Examples of 
fracture by direct violence are fractures of the calcaneum by falls upon the 
feet, fractures due to kicks, or falling timbers, or to being struck with a 
heavy instrument; and gunshot fractures. Direct fractures of shafts of 
long bones are quite often transverse to the axis of the bone broken. In 
fractures by indirect violence the fracturing force is conveyed through 
the intervening bones ; and the break occurs by leverage, torsion, or trac- 
tion. Such forces may produce transverse fractures, but more generally, 
oblique, spiral, or comminuted fractures. Examples of fractures by 
indirect violence are those of the clavicle from a fall upon the hand, 
oblique or spiral fractures of the tibia and fibula, fractures by torsion 
of the humerus in the so-called strength test, and fractures by traction 
at lower end of elbow and at ankle in forced flexion, extension, adduction, 
or abduction. 

Fractures by indirect violence more frequently involve the long than 
short bones because of their length, shape, and muscular and ligamentous 
attachments. Such injuries are modified according to the condition of the 
muscles of the part, the direction of the fracturing force, the position 
of the parts at the time of injury, and the anatomical structure of the 
bone involved. Thus from falls upon the palm of the hand are caused 
varying fracture lesions of the clavicle, humerus, or radius. Fracture 
through the base or lower end of the radius is the most common. 

Fractures by Muscular Action. — Bones may be fractured by the sud- 
den contraction of muscles; by contraction of muscles when a part of 
the bone is fixed so that leverage is produced; and by sudden muscular 
action producing abrupt arrest of the moving bone. Examples of the 
first class are fractures of the patella, of the olecranon, of the tuberosity 
of the calcaneum; examples of the second class are spiral or oblique 
fractures of the humerus in wringing out clothes, and in the so-called 
strength test with clasped hands of the contestants; examples of the 
third class are fractures produced by throwing, lifting, and shovelling. 
Other illustrations of fractures produced by muscular action are fractures 



4 TEEATISE OX FEACTUEES 

of the ribs from violent coughing, fractures of the bones of the leg in 
missing steps, fractures of long bones during the muscular convulsions 
of tetanus. 

The patella is the bone most frequently fractured by muscular action. 
Next in order are the olecranon of the ulna, the greater tuberosity 
of the humerus, occasionally the coracoid and acromion processes of 
the scapula, and many atypical fractures at the site of insertion of 
powerful muscles. Sprain fractures are often produced by mus- 
cular action. 

Gunshot Fractures. — In considering the etiology of gunshot fractures, 
one must bear in mind that the resulting lesions vary greatly, depending 
upon the velocity of the bullet, its size, the part of the bone involved, 
and upon whether the lesions are produced in military or civil life. The 
character of the fracture produced by the high-velocity bullet of war 
is entirely different from that produced in the ordinary revolver wound. 
Various degrees of bone lesion may occur. These may be classified as : 
(i) A fissured fracture of one side of the cortex. (2) A depression 
of the cortex. (3) A transverse comminuted or fissured fracture without 
perforation of the bone. (4) A perforation of the bone. When this last 
form occurs in the spongy bone near the articular end of long bones or 
in flat bones, there is generally no comminution. When the shaft of the 
bone is involved there is generally extensive Assuring, comminution and 
destruction dependent upon the line of the projectile. (5) Guttered or 
notched fractures may be produced when only a small portion of the 
circumference of the bone is involved. 

Fractures produced in military life with jacketed bullets are generally 
less extensive and less complicated by injury to soft parts than those 
caused by soft-nosed bullets, and by such missiles as were formerly used 
in war, and still are commonly fired in civilian gunnery. This is due 
to the high velocity of the bullet, its decreased size, its tendency to per- 
forate without extensive comminution, and to the fact that wounds pro- 
duced by it are, as a rule, aseptic. Disablement is produced by such small- 
calibre jacketed bullets, but mortality is less great. The aseptic condition 
of a wound or fracture depends, however, to a great extent, upon the 
relative cleanliness of the wounded man's skin and whether pieces of cloth- 
ing have been carried into the soft parts. A missile which has struck 
the soldier after ricocheting may be highly infective. The South 
African war between the Boers and the British seemed to establish these 
conclusions. The Great War in Europe between the German Empire and 
the allied powers seemed to prove the great difference between wounds 
contaminated with highly cultivated, and therefore frequently manured, 
soil and those which had come in contact with the earth in the sparsely 
peopled South African veldt. Fractures produced in civil life by the 
ordinary low-velocity large-sized bullet are generally more comminuted, 
the destruction of the bone is greater, injury to the overlying soft parts 



GENERAL considerations 



is more extensive, and infection is more frequent. Fractures produced 
bv bird-shot are rare, and are only possible when the distance is short, 
or the bone injured is very thin. The associated lesion of the soft parts 
is the chief characteristic, but in some the associated injuries to viscera 
are very important. Shrapnel causes great mutilation of all structures. 
Gunshot fractures due to exploding shells, or blows from heavy pieces of 
metal, are often greatly comminuted and may be accompanied by wide 
contusion and laceration of soft tissues. Infective osteomyelitis in such 
injuries therefore is almost certain, unless prompt removal of contami- 
nated structures is accomplished and the sterilization assured. 

Pathological Fractures. — This name is given to fractures, which 
follow some slight injury or only moderate muscular action, because of 



of the 
Pathologic fractures occur 




! 



a pathologic condition 
bone 

in bones in which there is. a brit- 
tleness or lack of resistance due 
to a local lesion or to a general 
disease producing a general fra- 
gility of the osseous structures. 
These fractures are sometimes 
termed spontaneous fractures. 
It can be readily understood that 
fracture may occur, under slight 
strain, in bones the seat of local 
lesions by which osseous tissue 
is softened, destroyed or re- 
placed by other forms of tissue. 
It has been observed by several 
authors that in patients, in which 
spontaneous fractures occur, 
there have been found varying 
quantities of phosphoric acid in 
the urine. It has been suggested 
that this is the result of decalcifi- 
cation of the bone by some meta- 
bolic process, the exact nature of which has not yet been determined by 
pathologists. These changes have been observed in cases of cancer 
and diabetes. 

Pathologic fractures may be classified as follows: (A) Fractures the 
result of local bone disease; and (B) fractures in which the rarefaction 
of the bone is the result of a general disease. 

A. Of the first class pathologic fractures have been observed in the 
following conditions : 

a. Inflammatory processes : infectious osteomyelitis ; tuberculous 
osteomyelitis. 



mm 



Fig. i.- 



Osteomyelitis (typhoid) of femur. Pathologic 
Patient fell while wearing a brace. 



fracture 



6 TREATISE OX FRACTURES 

b. New growths of bone: Sarcoma, primary (Fig. 4), and meta- 
static; carcinoma, metastatic (Figs. 5 and 6); benign bone cysts; mye- 
loma (albumosa) ; lymphomata, malignant, metastatic; metastatic tumors, 
thyroid in origin ; metastatic tumors from the adrenal ; echinococcus cysts. 




Pig. 2. — Cystic degeneration of humerus permitting pathological fracture. A man, 
aged 32 years, sustained fracture by fall against a chain; not a heavy blow. Had had 
pain in right humerus previously. Fracture was diagnosed by preternatural mobility 
with soft or almost no crepitus. Wassermann negative. Bone united without diffi- 
culty, though patient was given potassium iodide with mercury. Case may prove 

to be sarcoma. 

c. Aneurisms. 

d. Fracture the result of fragility of bones due to a general disease. 
B. Of the second class fractures have been observed as follows : 

a. Disease of the nervous system: locomotor ataxia; syringomyelia. 

b. Rickets, syphilis, scurvy, diabetes. 



G-EXERAL CONSIDERATIONS 



c. Osteomalacia, osteitis deformans, imperfect osteogenesis of un- 
known origin. 

d. Rarefaction from chronic diseases affecting metabolism. 
Fractures in Utero. — Intra-uterine fractures are chiefly fractures 

and pathologic fractures. The traumatic fractures are the result of 
external violence. Pathologic intra-uterine fractures are generally the 
of the mother. Children have been born with one or more fractures, 
some in a state of partial union in which there has been no history of 

external violence. Pathologic 
intra-uterine fractures are gener- 
ally the result of syphilis, rickets, 
osteochondrosis, parenchyma- 







Fig. 3. — Pathologic fracture of humerus. After treatment. 
(See Fig. 2.) 



Fig. 4.- 






-Sarcoma of right humerus. Patho- 
logic fracture. 



tous osteitis or amniotic adhesions. Very often it is difficult to differen- 
tiate intra-uterine from intrapartum fractures. Imperfect development of 
the skeleton may cause defects resembling fractures of the long bones. 

Intrapartum Fractures. — Fractures may occur during delivery. They, 
as a general rule, are the result of disproportion in the size of the foetus 
and the pelvis, unusual position of the foetus, or undue haste or faulty 
management of the delivery. The bones most frequently fractured are 
the femur, humerus, clavicle, tibia and fibula, radius and ulna. The 
most common lesion is epiphyseal separation, although fractures of the 
shaft of the bone may occur. 



8 



TREATISE OX FRACTURES 



Varieties of Fractures. — Fractures should be classified as to variety 
as follows : 

A. Fractures considered in relation to the condition of the surround- 
ing soft parts: Fractures are divided into two classes : ( i ) closed frac- 
tures; and (2) open fractures. A closed fracture is one in which there 
is no communication between the outside air and the seat of fracture. 
They are sometimes designated as simple or subcutaneous fractures. 
An open fracture is one in which the seat of fracture is exposed to 
atmospheric contact through a wound of the muscles, fascia and skin. 
These fractures are sometimes called compound fractures. The open 



Pig. 5. 



Fig. 6. 





ogic fracture of right femur, due to metastasis from carcinoma of left breast, operated 
two years previously; local recurrence in scar, left axillary and supraclavicular regions. 
Fig. 6. — Pathologic fracture of right humerus due to metastatic growth from primary carcinoma of 

prostate gland. 



character of the fracture may be caused by the direct vulnerating force, 
by thrust of the end of a fragment through the soft parts by the fracturing 
force or by the weight of the unsupported limb, or by subsequent ulcera- 
tion or sloughing of the overlying soft parts. It can be readily under- 
stood that open fractures are more dangerous and may lead to more com- 
plications than closed fractures, because of the ease of entrance of infect- 
ing organisms. If contamination is averted or aseptic closure attained, 
before contamination has become infection, open fractures heal and 
become united almost as readily as closed injuries of bone. Infection 
followed by osteomyelitis and septicaemia may occur, necessitating ampu- 
tation occasionally as a last resort. Death is not unusual in infected 
fractures, unless the lesion is treated with an aseptic or antiseptic technic 



GENERAL CONSIDERATIONS 9 

and great surgical skill. Industrial and military fractures are especially 
liable to be both open and infected. 

B. Fractures classified according to degree: Fractures may be classi- 
fied as (i) incomplete, and (2) complete. 

1. Of the incomplete fractures (Fig. 8) there are: 

(a) Fissures. This form of fracture consists in a linear break 
without separation of the fragments to any appreciable extent. The 
most frequent sites are the vault and base of the skull; and the humerus 
and tibia. When they involve the long bones they as a rule begin at the 
articular surface. 

(b) Infraction; green-stick or true incomplete fracture. This is a 




Fig. 



7. — Showing result of too early weight bearing after cure of syphilitic fracture of tibia and 
fibula at ankle. Patient also has Charcot knee-joints. 



fracture involving only a portion of the diameter of the shaft with bending 
or angulation of the remaining fibres at the point of fracture. It occurs 
in children, whose bones are normally elastic from a relatively large 
amount of organic material in their composition. It happens most fre- 
quently in the bones of the forearm, clavicle, tibia, femur and humerus. 
Such fractures may happen in softened bone of adults. 

(c) Depressions or indentations. This variety of fracture is a driv- 
ing in of the cortex of the bone, without complete fracture, as a result 
of direct external violence. It is most commonly observed in the skull, 
involving the outer table, and in the spongy bones. 

(d) Splitting off a portion of the cortex. This is a separation of 



10 



TEEATISE OX FBACTT7BES 



the fibres of the cortex, with possibly a part of the underlying spongy- 
bone as a result of direct violence. It does not involve the entire thick- 
ness of the bone and is generally produced by a sharp-cutting instrument 
like an axe or sabre or by the impact of a projectile. 

(e) Separation of an hypophysis; sprain-fracture. These fractures 
occur as a result of violent and sudden muscular action, tearing off a 
small process of attached bone, or are due to a sudden increase of tension 
upon a ligament, producing the same result. Sprain-fracture is very 
frequent according to Ross and Stewart, who estimated it to occur in 




e f 

FlG. 8. — Types of fractures: (a) fissure; (b) infraction; (c) depression or indentation: (d) splitting of a 
portion of cortex; (e) separation of an hypophysis; (/) sprain fracture. 

15 per cent, of all fractures. The lesion generally consists of the tearing 
off of a small scale of bone close to a joint, to which a muscle, tendon, 
or ligament is attached. 

2. A complete fracture is one in which the line of fracture involves 
the entire thickness of the bone, separating it into two or more fragments. 

C. Fractures considered in relation to the direction and character of 
the line of fracture (Fig. 9) : 

(a) Longitudinal. Longitudinal fractures are those in which the 
line of fracture is not further from the long axis of the bone than 15 
or 20 degrees. They are extremely rare, except in perforating fractures 
such as are caused by gunshot wounds. 

(b) Transverse. In this variety the plane of fracture makes nearly 
a right angle with the long axis of the bone. Transverse fractures are 
rare. They are most frequently found in the lower end of the radius, 
the middle of the humerus, the patella, and the flat bones. At times 
they are caused by muscular action. 

(c) Oblique. This variety is characterized by a single or double line 



GENERAL considerations 



11 



of fracture, making an angle with the long axis of the bone; which is 
neither that of a longitudinal nor that of a transverse fracture. The 
majority of fractures are oblique. It is most commonly observed in 
fractures of the shaft of the humerus, tibia and femur. 

(d) Spiral. In this variety the line of fracture is a prolonged oblique 
fracture encircling the entire circumference of the bone. It is produced 
by torsion, or twisting, when a part of the extremity is fixed. The tibia, 
humerus, and femur are most frequently involved. A sub-variety of this 
fracture is the third fragment fracture, which consists of a small third 
fragment being detached at the seat of the spiral fracture. This type of 
fracture is also seen in some types of oblique fracture. 

(e) Subperiosteal. This term is given to that form of fracture 
generally transverse in direction in which there is no separation of the 
fragments and the periosteum is not lacerated. Such lesions generally 




a be d e f g h i j 

Fig. 9. — Fractures considered in relation to the character and line of fracture: (a) longitudinal frac- 
ture; (b) transverse; (c) oblique; (d) spiral; (e) subperiosteal; \f) V-, T-, or Y-shaped; (g) compression; 
(h) comminuted; (z) impacted; and (j) crushing. 

result from direct violence, and are most frequently seen in the tibia 
and radius and ulna. 

(/) V-, T-, or Y-shaped. These fractures are so named from the 
direction of the lines of fracture resembling the letters named; and are 
most frequently seen at the lower end of the humerus and the lower end 
of the femur. 

(g) Compression. Compression fractures are those due to a driv- 
ing together of the cortical and spongy layers of bone as a result of 
condensing force. They are seen most frequently in the calcaneum, 
astragalus, and vertebrae, and result most frequently in falls from a 
height, when the patient lands on the soles of his feet. 

(h) Comminuted. When there are not only two fragments, but 
the bone has been extensively splintered at the seat of fracture, the injury 
is termed a comminuted fracture. This form is seen most frequently in 
the long bones as a result of gunshot injuries or when the bones have sus- 
tained injuries from great forces or are brittle because of senile changes. 

(i) Impacted. This form of fracture is the result of violent driving 
of the end of one fragment into the end of the other at the time of injury, 
so that the fibres become interlocked and immobility of the pieces is pres- 



12 



TREATISE OX FRACTURES 



ent. It is seen chiefly in fractures at the neck of the femur, lower end 
of the radius, and the surgical neck of the humerus, where one fragment 
consists largely of spongy osseous tissue. 

(;) Crushed. This variety of fracture is seen as a result of direct- 
violence, as when a heavy body, like the wheel of a wagon, passes over 
the foot. It is a form of comminuted fracture and is found most fre- 
quently in the carpal or tarsal bones. It differs from the compression 
fracture in that the latter is the result of indirect violence, as a rule, 
while the former is due to direct violence. 

D. Fractures considered in relation to the position of fracture 








a b c 

Fig. io. — Fractures considered in relation to 

the position of the fracture: (a) upper end; (b) 

shaft; and (c) lower end. 





FiG. ii. — Articular fractures: {.a) intra-articular; 
(b) para-articular; and (c) true articular. 



(Fig. io ) : Fractures are generally referred to as involving certain por- 
tions of a bone, such as fracture of the shaft, fracture of the upper or 
lower ends of a bone; fractures of certain parts of the shaft, as fracture 
of the middle of the shaft of the femur; fracture of certain prominences, 
such as fracture of condyle, or apophysis. 

E. Fractures involving a joint or articular fractures are those frac- 
tures in which the joint surface is involved in the line of break (Fig. 1 1 ). 
They comprise three classes : ( I ) Intra-articular fractures in which the 
line of fracture is entirely within the joint; (2) para-articular fractures 
in which the line of fracture is near the joint, so that subsequent healing 
may directly interfere with joint functions, and (3) true articular frac- 
tures in which the line of fracture involves both intra- and extra-articular 
bone. All of these fractures may vary from a simple fissure with no 
laceration of the capsule to an extensive comminuted fracture with 
extensive lacerations of the capsule. The most common type of articular 
fractures are those of the neck of the femur, of the lower articular 
end of the humerus, of the lower end or the head and neck of the radius, 
fracture about the ankle-joint, and fracture of patella and of the olecranon. 

F. Epiphyseal separations: These consist in a partial or complete 
separation of the epiphysis from the diaphysis before the time when 



GEXERAL CONSIDERATIONS 



13 



ossification takes place in the epiphyseal cartilage. In females the last 
epiphysis unites about the twenty-third and in males about the twenty- 
fifth year. The epiphyses most frequently involved are lower epiphyses 
of the femur, radius and humerus, and the upper epiphysis of humerus. 
In epiphyseal separations there is generally a portion of the diaphysis 
carried away with the epiphysis. The injury is usually the result of 
excessive strain upon the articular ligaments. There is always the possi- 
bility of arrest of growth in the bone affected, due to faulty replacement 
of the epiphysis or to premature ossification of the epiphyseal cartilage. 
G. Fractures considered in relation to the number of fragments: 
In contradistinction to the varieties of fracture which presuppose that 
the break is limited to or radiates from one point, there are multiple 
fractures (Fig. 12, a). This term is applied to fracture of two or more 
bones, and sometimes to more than two non-communicating lines of 
fracture in a single bone. Fractures occurring in two adjacent bones, 





a b 

Fig. 12. — Fractures considered in relation to the number of fragments: (a) multiple fracture; and (b) 

double fracture. 

like the ulna and fibula, are not designated as multiple fractures. The 
term double fracture (Fig. 12, b) is applied to two unconnected lines of 
fracture occurring in the same bone. Multiple fractures are usually 
the result of direct external violence, and frequently the force is very 
great. Fractures of this variety are often troublesome to treat satis- 
factorily, because of the difficulty of enforcing quiet upon the patient. 
There may be, in addition, considerable destruction of the overlying 
soft parts on account of the degree of the violence sustained at the 
time of injury. 

Displacement of Fragments. — The relative position of the fragments 
of a broken bone gives rise to several forms of displacement. While the 
classification of Malgaigne has been, as a rule, adopted in considering 
displacement of fragments, it should be realized that the deformity 
is generally a combination of two forms of displacement As a rule 
it is the distal fragment which occupies the abnormal position. Trans- 
verse fracture of the olecranon and patella are exceptions to this rule. In 
comminuted fractures the displacement is too complex in nature to 
permit of classification. 



14 



TEEATISE OX FEACTUBES 



Varieties of Displacement (Fig. 13). — The forms of displacement 
may be classified as : 

(1) Angular displacement, or tilting, in which the axes of two 
fragments make an abnormal angle with each other. This form of 

.displacement is commonly seen in green-stick fractures. 

(2) Rotary displacement is due to rotation of one fragment on its 
long axis. The rotating fragment is generally the distal, or lower, the 
fixed fragment is the proximal, or upper, one. The best example of this 
type of displacement is seen in fracture of the neck or shaft of the femur. 

(3) Transverse displacement consists in a deviation of the fragments 
anteroposterior^ or laterally or a combination of the two. This form 
is very rare, and is seen generally in combination with some other form 






a b c d e f 

Fig. 13. — Varieties of displacement of fragments: (a) angular; (b) rotary; (c) transverse; (d) longitudinal; 
(e) impaction or crushing; and (/) longitudinal with separation. 

of displacement. The usual position of this form is in transverse fracture 
of femur or humerus. 

(4) Longitudinal displacement is a change in the length of the bone. 
Overlapping of the fragments is the common form. It is generally com- 
bined with other varieties of displacement, and is most common in oblique 
and spiral fractures. Separation of fragments occurs in fractures of 
patella and olecranon. 

(5) Impaction and crushing displacements consist in the penetration 
of a broad fragment of a narrow one (impaction) or in the destruction 
of the osseous structure into small pieces (crushing). Impaction causes 
fixation and is often accompanied by rotary displacement; it is most com- 
mon in fractures of the neck or through the trochanters of the femur, 
fractures of the upper end of the tibia, and of the lower end of the radius. 
Crushing displacements are most commonly seen in fractures of the 
tarsal bones. 

(6) Diastasis should be applied only to epiphyseal separations. It 



GENERAL CONSIDERATIONS 15 

is sometimes used for a separation of the fragments of the bone in 
fractures such as occur in breaks of the patella and olecranon. 

Fractures in Which No Displacement Occurs. — In some varieties 
of fracture there is no displacement of the fragments. This may be 
due to ( i ) incompleteness of the line of fracture, as in fissure fracture ; 
(2) to the fragments being held together by the surrounding periosteum 
and muscles, and occasionally by a parallel bone, as in subperiosteal 
fractures and fractures of the forearm and of the fibula; and (3) to the 
support of surrounding fascias and ligaments, as in some fractures of 
the patella and olecranon 

Etiology of Displacement of Fragments. — Displacement of fragments 
is due to several causes. The chief are the fracturing force, muscular 
contraction and the action of gravity on the distal fragment. (Edema 
and infiltration of the soft parts, and especially muscular spasm, keep 
up deformity. Muscular action in nearly every instance causes shortening 
from overriding. In fractures of the patella, olecranon, and separation 
of epiphyses and apophyses the longitudinal deviation may cause separa- 
tion of the pieces of bone. This is due to the powerful muscular attach- 
ment to one of the fragments. It is not always possible to predict the 
character and extent of displacement that will occur in a fracture at a 
given locality, for it depends on the direction and nature of the line of 
fracture as well as on the muscular attachments. Displacements occur 
more frequently and in greater variety in oblique and spiral fractures 
and less frequently in transverse fractures. 

Symptomatolgy. — The examination of every case of suspected 
fracture should proceed in a systematic manner. A careful history of 
the accident, its nature and time should be first obtained. The previous 
history should be noted, and the possibility of a pathologic fracture and 
of deformities from previous injuries should be remembered. The 
patient should be examined as soon as possible after the receipt of the 
injury, unless there is marked shock present. In this way one may often 
detect fractures more readily, because swelling, ecchymosis, and spasm 
of the muscles have not taken place. If, however, there is considerable 
shock present, it is advisable to defer examination until it has passed. 

All clothing that may interfere with a careful examination of the 
part should be removed. It is also advisable to remove the clothing from 
the same part of the opposite side, so that the anatomical landmarks 
of the uninjured and injured sides may be carefully compared. This 
simple expedient will enable the surgeon to make a proper examination 
and help him arrive at an accurate diagnosis. 

In many cases it is advisable to use a general anaesthetic, so that a 
thorough examination may not be prevented by reason of pain and 
muscular spasm. In children this is especially true, and anaesthesia is 
frequently required. At the same time reduction and immobilization 
may be performed. 



16 TREATISE OX FRACTURES 

The symptoms produced by a recent fracture may be divided into two 
classes: objective symptoms and subjective symptoms. The objective 
symptoms are deformity, abnormal mobility of the part, crepitus, and 
oedema and ecchymosis. The subjective symptoms are pain and tender- 
ness, loss of function or impaired motion, intermittent muscular spasm. 

Deformity. — This is principally due to the displacement of frag- 
ments. Deformity is not always present. Fissure fractures and some 
impacted fractures give little if any deformity. Deformity is determined 
by inspection, palpation, and measurements of the parts. It is the result 
of several factors. These are, the fracturing force, the weight of the 
distal portions of the limb, the pull exerted by certain groups of muscles, 
and the oedema and ecchymosis infiltrating the soft parts about the seat 
of fracture. 

In many cases inspection will show the presence and site of fracture, 
which are confirmed by palpation. The non-injured side or symmetric 
part should always be examined and compared with the injured part. In 
considering the degree or existence of deformity, previous fractures 
and injuries should be taken into account, as well as exostoses, periosteal 
nodes, and shortening from chronic inflammatory conditions of joints 
and contracted tendons. The recurrence of deformity when restraining 
forces are relaxed is often a distinguishing characteristic of fracture 
and serves to differentiate it from dislocation. Careful and repeated 
measurements from fixed bony points should always be made. This is 
only reliable in estimating shortening when the two sides are placed in 
the same relative positions ; and then there is always some element of 
doubt if the subject is obese or there is moderate deformity or oedema. 
It should always be remembered that often there is an inequality in the 
length of the normal bones of the two halves of the body. This at times 
has been found to be from one to one and a half inches in the lower 
extremities. This asymmetry of uninjured long bones of the upper 
and lower extremities has an important bearing in medico-legal cases. Its 
relation to the prognosis in fracture treatment is readily seen. 

Abnormal Mobility of the Part. — This is absolute proof of a 
fracture, excepting in very extensive dislocations. Abnormal mobility 
is sought by endeavoring to move one portion of the bone independently 
of the other. In doing this one may produce one or more of the various 
types of displacement. Absence of mobility must not be assumed until 
all forms of displacement have been attempted, as it is likely that displace- 
ment may be possible only in certain directions. Abnormal mobility is 
absent in incomplete, subperiosteal, and impacted fractures, and occasion- 
ally in fractures involving joint surfaces. When one of two bones is 
broken the abnormal mobility may be slight. In some fractures the normal 
elasticity of the part or the proximity of a joint may simulate abnormal 
mobility and mislead the examiner. Error may thus occur in injuries 
of the sternum, ribs and fibula; in hurts near joints, because, there, motion 



GENERAL CONSIDERATIONS 17 

is the normal condition; and in fractures in which the fragments are 
so small or deep-seated that they cannot be firmly grasped. This diagnos- 
tic difficulty is observed often in fractures of the anatomical neck of the 
humerus, metatarsal fractures, and in atypical fractures of the upper 
end of the femur. 

Abnormal mobility may be readily demonstrated in the shaft of a 
bone broken near its middle by placing the hand under the part at the 
supposed seat of fracture and endeavoring to raise it with this single 
point of support. Motion and angular displacement immediately result. 
It may also be determined in some cases by placing a finger of each hand 
upon the supposed upper and lower portions of a small fragment and 
producing a rocking motion. This may be seen in fractures involving 
the lower two inches of the fibula or of the ribs. 

Crepitus. — This is a rubbing sensation, conveyed to the examiner's 
hand, and is produced by forcible manipulation of the parts. The motion 
may give rise to a grating sound audible to the bystanders. In order that 
crepitus may be produced, certain factors are necessary. The ends of 
the fragments must be in apposition or capable of being brought into 
apposition by the surgeon or a third person, causing traction when manipu- 
lation is made. It is absent in impacted, green-stick, and incomplete 
fractures. It cannot be produced if the ends of the fragments are 
separated, as in fractures of the olecranon and patella, if there is marked 
overriding so that smooth portions of the bone are in apposition, or if 
portions of muscle, fascia, ligament, or other structures intervene. In 
old fractures, when the ends of the fragments have become covered with 
fibrous tissue, and in delayed union of fractures or pseudo-arthroses true 
crepitus is no longer to be elicited. In pathologic fractures the bone may 
be too soft to cause true crepitus. 

Fracture crepitus may be confounded with joint crepitus, with the 
fine crackling noted in inflammatory conditions of tendon sheaths and 
bursas, and with various sounds resulting from cellular emphysema and 
pleuritic adhesions. The crepitus made upon manipulation may be 
discernible to the patient. It can often be distinguished by placing the 
palm of the hand over the seat of the injury, as in fracture of the ribs. 

(Edema or Swelling. — This can hardly be classified as a distinct 
symptom of fracture because subcutaneous pouring out of blood and 
serum occurs in all severe injuries, yet it occurs so frequently with any 
forms of fracture that its importance should not be neglected. This 
serous or bloody swelling may be rapid and appear not only as generalized 
infiltration of the soft tissues surrounding the fracture, but may be shown 
by blebs or small vesicles occurring on the surface. These are filled 
with turbid or bloody serum. 

Ecchymosis. — Bleeding into the interstices of the tissues, as a result 
of contusion of the soft parts overlying the broken bone, occurs within 
the first twentv-four hours. Ecchvmosis appearing after the lapse of 
2 



18 TREATISE OX FRACTI7KES 

several days indicates that the blood has escaped from deep structures. 
This may begin to show after the first twenty-four hours, or may not 
be seen for four to five days. It is generally indicative of a fracture. 
The time of its appearance is due to the difficulty of reaching the surface 
through periosteum, muscles, and fascia. It may occur at a distance from 
the seat of fracture and shows in a dependent part of the body or limb, 
which it reaches by gravity. Very often ecchymosis is accompanied 
by the occurrence of blebs, and in some cases the parts may be so badly 
discolored as to lead the inexperienced to diagnose gangrene of the part. 
The absorption of the blood is generally very tardy, and the fracture may 
be firmly united before the final disappearance of the extravasation. 

Pain and Tenderness. — Pain is a usual symptom in fractures. It 
varies greatly in severity. In fissured, incomplete, or impacted fracture 
pain may be slight. Pain is great in fractures involving a single support- 
ing bone of a part, and in those in which a nerve is caught between the 
fragments or pressed upon by infiltration of the soft parts or by callus. 
Pain as a rule is not great when the fragments are separated. Tenderness 
is noted particularly in fractures produced by direct violence. It is of 
diagnostic value in differentiating obscure fractures from contusions and 
sprains; and in determining the seat of a lesion in periosteal frac- 
tures, sprain fractures, in fractures of the carpal bones, and in deep- 
seated fractures. 

Loss of Function. — In the presence of fractures this may be the 
result of pain, or it may be due to the loss of continuity in the bone. 
Motions which do not give pain at the seat of fracture and which may 
be performed by reason of a supporting parallel bone may be accomplished 
in many cases. This is particularly so in fractures in which certain 
motions do not bring stress at the seat of fracture. Loss of function may 
be absent in incomplete, partial, and impacted fractures. It is a common 
occurrence to see patients walking around with fracture of the lower end 
of the fibula; and sometimes this is possible even in fractures of the 
upper end of the femur. 

Intermittent Muscular Spasms. — These are often present and 
may cause great pain. They result from stimulation produced by excita- 
tion of terminal nerve filaments in the muscles about the seat of fracture. 
Numbness and occasionally complete paralysis may be present as a result 
of pressure upon a nerve, laceration, section, or complete destruction of a 
nerve, at the time of injury or by subsequent pressure of the fragments 
or by callus. The musculo-spiral, ulnar, and external popliteal nerves are 
quite liable to injury accompanying fractures of the humerus and femur. 

The constitutional symptoms of fracture are those of shock or of a 
subsequent inflammatory process. In the usual closed fracture consti- 
tutional symptoms are generally slight. There may be a slight rise of 
temperature noted during the first three to four days. In open fractures 
the constitutional symptoms are those that occur as a result of the com- 



GENERAL CONSIDERATIONS 19 

plications of open fractures. In old age the constitutional symptoms are 
liable to be more marked, and fractures may have serious terminations 
from sequelLne in the senile that are rare in the young. 

Diagnosis. — Deformity, preternatural mobility and crepitus are char- 
acteristics of a break in a bone. In suspected fracture the diagnosis may 
often be readily made; but there are cases in which several of the symp- 
toms of fracture are lacking, and therefore the diagnosis extremely diffi- 
cult. In these instances careful examination should be made under 
general anaesthesia and comparison made with the opposite symmetri- 
cal parts. 

Diagnosis is difficult in fractures near joints. The chief causes are 
normal mobility present at a joint, and the difficulty of firmly grasping 
the small fragments so as to elicit the objective signs of fracture. It 
must be recollected also that synovitis may cause a roughening of the 
joint surfaces, which gives to the surgeon's fingers, during motion for 
examination, a crepitus resembling fracture crepitus. Joint crepitus 
is less grating than the crepitus of a recent fracture. Crepitus from a 
fracture several days old is soft, however, and almost identical with 
fracture crepitus. The most characteristic signs of articular fracture 
are effusion into the joint, generally bloody in nature, and mobility greater 
than that found normally at the involved articulation. 

Dislocations may be confused with fractures near joints; but in dislo- 
cations the normal motions of the articulation are impaired, and there 
is generally a sudden or abnormal check to free movement in some 
directions on manipulation by the examiner. In fractures the movements 
are generally preternatural ; they may be unlimited. Spontaneous recur- 
rence after reduction of dislocations is very infrequent, while in fractures 
deformity is liable to be reproduced when fixation is removed. In dislo- 
cations, voluntary motions are not as impaired as in fractures, and there 
is more rigidity, while in fractures there is the appearance of helplessness. 
In dislocations, specific positions of the part are impossible on account 
of the change in bearing points of the articulation, and the relations of 
the normal bony landmarks of the joints are changed. 

Fractures may be differentiated from epiphyseal separations by noting 
the site of the suspected fracture, by considering the age of the patient, 
by the character of the crepitus, which is soft and more indistinct than in 
fractures, by the tendency toward slight displacement, and by the 
localization of the abnormal mobility and pain at the level of the epiphy- 
seal cartilage. Separations of epiphyses are often followed by diminished 
growth in the length of the bone due to the involvement of the epiphyseal 
cartilage. Epiphyseal separations are frequently accompanied by a 
fracture of the meta-epiphyseal end of the diaphysis, and rarely by a 
splitting of the epiphysis. 

At times it is difficult to determine the exact location and line of 
fracture. This very important information may usually be determined 



20 



TREATISE OX FRACTURES 



by careful palpation under general anaesthesia, measurements from known 
fixed points, and the position of various related prominences. Often the 
exact line of the break can be only inferred unless X-ray examinations 
are made in two planes. In fractures without deformity or crepitus the 
localized pain and tenderness present may enable the line of break 
to be recognized with reasonable probability. 

Many fractures are overlooked at the time of injury and are only 
discovered afterward by the presence of callus, by the persistence of pain 
and tenderness, or by loss of function of the part. This error occurs in 
fractures of the ribs, metacarpals, carpals, tarsals, sternum, and forearm; 

and in incomplete, sub- 
periosteal, impacted, and 
sprain fractures. Many 
of the symptoms of 
fracture may be absent 
in these injuries. 

Rontgen Rays in 
the Diagnosis of Frac- 
tures. — The use of the 
Rontgen rays in the 
diagnosis of fracture 
and injuries to joints is 
of great value. They 
not only show the line 
of fracture but also the 
number and relation of 
fragments. An excep- 
tion to this, however, is 
their use in certain 
types of early epiphy- 
seal separations. The 
Rontgen rays, how- 
ever, should not be em- 
ployed to the exclusion of other means of diagnosis. They are of 
especial value in deep-seated fractures, in fracture near joints, in fractures 
of the carpal and tarsal bones, in sprain fractures, and evulsion fractures. 
Careful examination and skilled interpretation of the X-ray plate should 
be painstakingly made. The fluoroscopic examination may be sufficient, 
especially if the injured bones are viewed in two or three different planes; 
but usually the X-ray plates give a better opportunity for careful study. 
At least two plates taken in planes at right angle to each other are needed 
in doubtful injuries. The plates should be placed in a shadow box for 
study. Stereoscopic plates will often be of great value in diagnosis of 
the exact condition of the bone and the integrity of the readings. Read- 
justment of the fragments by manipulation, while the surgeon uses the 



. 




Fig. 14. — Rontgenogram of green-stick fracture of femur by torsion in 
infant, 22 months old, after reduction under ether anaesthesia. Antero- 
posterior view shows perfect alignment and fracture might easily be 
overlooked but for clinical history. (Dr. Roberts's patient.) Compare 
Figs. 19a and 20. 



GENERAL CONSIDERATIONS 



21 



fluoroscopic screen for guidance, is sometimes very satisfactory. The 
result of the bone setting, however, always must be verified by the sur- 
geon's intelligent examination of the limb, after leaving the dark fluoro- 
scopic room. Every surgeon should familiarize himself with the X-ray 
photographs of the normal bones; especially with the articular portions 
and the appearance of the epiphyses at all ages up to their consolidation 
with the metaphyses. 

Fig. 15. 







Fig. 14a. — Rontgenogram of green-stick torsion fracture of femur in 22 months infant, showing slight lateral 
curve by reason of X-ray tube being placed in different relation to limb than in Fig. 19. Reduction had been 

done under ether just before X-ray plates were taken. Compare Figs. 19 and 20. 
Fig. 15. — Lateral view of green-stick torsion fracture in child, 22 months old, after reduction under ether of 
a one-week-old injury. Clinical examination before anaesthesia showed evidence of a green-stick fracture. 
Reduction rather difficult under ether but fracture made evident by restoration of contour and some crepitus. 

Compare Figs. 19 and 19c. 

If there is an X-ray equipment at hand, it may be used routinely in 
the study of suspected fractures. Thus will a surgeon become familiar 
with the radiographic aspects of the normal skeleton. He will also make 
many more correct diagnoses of obscure injuries, and he will be better 
able to make diagnoses in fractures from previous knowledge gained in 
X-ray plate interpretation when an X-ray examination is not feasible. 
Examination of an injured extremity under general anaesthesia with ether, 
to relax the muscles and avert pain, will often give an intelligent examiner 



22 TEEATISE OX FEACTTTEES 

more reliable information of the nature and proper treatment of a 
fracture than the fluoroscope or the X-ray photographic plate or print. 
A great advantage of making a diagnosis under anaesthesia is the ease and 
celerity with which ether usually can be obtained. The satisfactory way 
in which the fragments may be coapted and retaining dressings applied, 
after the diagnosis has been made, makes resort to this method ideal. 
Routine fluoroscopic examination is probably not advisable. While it is 
useful in gross fractures, it does not show small obscure lesions, unless 
one is carefully trained in its use. The necessary repetition of fluoro- 
scopic examinations is dangerous to the examiner and the patient. Burns 
of the skin may occur. The first X-ray negative, if practicable, should 
be taken before reduction of the fracture; another after reduction is 
sometimes very desirable. 

In some cases repeated X-ray negatives should be made at intervals 

__, of five days to a week, so as to 
note the position of the fragments. 
Many errors of interpretation are, 
however, possible. The shadow 
produced on the X-ray negative is 




1 



■v',V 



the result of different opacities of 
the parts rayed and is not a photo- 
graph of the position of the frag- 
ments. Distortion of the parts, in- 
correct adjustments of the tube, the 
relative distance of the parts from 
the plate, the various angles of in- 
cident rays to the part, and the sur- 
rounding dressings tend toward 
error and misinterpretation of the 
plate. When possible two nega- 
tives of the varied bone opacities 
should be made in planes at a right 

Fig. 16. — T\ormal hand of child two years of age. * o 

Epiphyses and carpus still cartilaginous. Centres an^le. The X-raV olate may show 
of ossification appearing. & J r -< 

displacement of fragments when 
none of surgical moment exists. This may readily vary with changes 
in the relative positions of the Crooke's tube, the photographic plate 
and the patient. 

It is only by great care in the taking of X-ray negatives, by long 
practice in the interpretation of the plates, and by the comparison of 
findings from this source with those from clinical examination of the 
injured parts that the Rontgen ray becomes of greatest service in the 
diagnosis and treatment of fractures. Rontgenography, like microscop- 
ical findings and other results of specialized study, may be of the most 
vital value in determining alterations in the condition and relations of 
human structures. The surgeon, however, must add his knowledge of 



GENERAL CONSIDERATIONS 



23 



anatomy, physiology and mechanics to the solution of the problem, 
if he is to give his patient the best service. The radiologist is often no 





Fig. 17. — Normal hands, with epiphyses of radius and of ulna still ununited. Not to be 
mistaken for fracture. Boy, 7 years. 




:.<r,-.^-:-;- ,;";';. -, ■ ^."^v.:-- 




Fig. 18. — Normal thorax and shoulders of child of 2 years. Epiphyses of humeri ununited to 
shafts and cartilaginous. Ribs and vertebras normal. Note shadow of heart. 



surgeon and the surgeon very often no radiologist. Each must have 
a share in the interpretation of the X-ray plates and ought therefore to 
have some practical experience in each other's science (Figs. 16-20). 



24 



TREATISE OX FRACTURES 





Fig. 19a. — Tibial and calcaneal epiphyses normal. Boy 
of 8. Ankle-joint operated to secure ankylosis in paralysis. 



Fig. 196. — Normal knee. Boy, 5 years 

of age. Epiphyses still separate from 

diaphyses. 




Fig. 20. — Normal hip-joints. Child aged 3 years. 



GENERAL COXSIDEKATIONS 25 

Repair of Fractures. — Repair in Recent Closed Fractures. — 
The repair of fractures does not differ materially from the repair which 
takes place in other tissues. The variation in the process of repair de- 
pends generally upon two factors : ( i ) proper anatomical apposition of 
the fragments; and (2) the proper nutrition of both fragments. Less 
callus is formed, union is more prompt, and disability less when perfect 
anatomical apposition is obtained and maintained. On the other hand, 
if the fragments are not placed in perfect apposition and so maintained, 
there is more irritation at the ends of the fragments, which causes an 
increased amount of exudation and callus. Union may be delayed or 
arrested, if the fragments are not maintained in place; or it may be 
obtained only by a great production of callus, such as is seen at times in 
fractures occurring among the insane. When one fragment has deficient 
or no blood supply, repair may be arrested and at times ceases. 

Repair in fractures is carried on by two structures, the periosteum 
and the medulla, furnishing an osteogenetic bond or callus. 

At the moment of injury there is more or less tearing and bruising of 
the periosteum, with rupture of blood-vessels of the periosteum and of 
the bone. The immediate result is interstitial hemorrhage, with effusion 
of fluid and an infiltration of leucocytes in the surrounding structures. 
This infiltration continues about four to six days. At the end of forty- 
eight hours there is proliferation of the cells of the periosteum and 
medulla and this is soon accompanied by a like proliferation of the 
endothelial cells of the involved blood-vessels, so that at the end of the 
fourth day there is a definite osteoblastic tissue formation. Microscopi- 
cally this consists of large polymorphonuclear cells, many mitotic figures, 
and a fibroid stroma. This tissue is rapidly changed into chondroid and 
osteoid tissue which soon becomes bone. 

At the end of a week the ends of the bone are surrounded by a spindle- 
shaped sheath, made up of osteophytes, osteoid spicules, and fibroblastic 
stroma. This is called callus, and may be divided into three forms : 
periosteal, or ring callus, which is external to the bone and surrounds 
the seat of fracture; intermediary callus, which is a prolongation of the 
periosteal callus between the ends of the fractured bones; and myelogenic 
or internal callus, which extends a short distance up and down the medul- 
lary cavity of the shaft at the seat of fracture. Callus is also spoken of 
as provisional callus, consisting of bone produced in excess, and definite 
callus, which occurs between the ends of the bone and is permanent. 
The callus is produced by the osteoblasts, and later changes into osteoid 
and finally into osseous tissue. 

With these changes are found blood-vessels extending into the callus, 
the process being similar to that seen in embryonal bone formation. These 
vessels enter the callus from the periosteum, the endosteum, and the 
fractured ends of the bones. As this process proceeds and vasculariza- 
tion is complete, the callus has been changed in places into hyaline cartilage 



26 TREATISE OX FRACTURES 

and fibrous connective tissue. This is followed by the formation of bony 
lamellae about the blood-vessels, and the production of Haversian systems 
and true bone formation begins. In this manner the callus is slowlv 
changed into dense bony tissue until the fragments are firmly joined and 
the process of union is complete. Coincident with this stage there begins 
an absorption of the periosteal and endosteal callus, which if not removed 
would often interfere with the function of the parts. This absorption is 
carried on by the activity of the osteoclasts. The process is one of months 
or years, depending upon the amount of excessive callus and the degree 
of deformity. It finally results in the removal of all excessive callus, 
both periosteal and myelogenic, and in the rounding off of all irregulari- 
ties. Where there was at first an excessive amount of callus, there finally 
results a symmetrical bone. In some fractures in which very little dis- 
placement of fragments occurs, the process may be so perfect that it may 
be impossible to determine the seat of fracture, and a longitudinal section 
of the bone will show a continuous marrow cavity. 

The size of the callus depends upon the extent of the fracture and 
the displacement of the fragments. Comminuted fractures associated 
with a great degree of separation of the fragments are followed by the 
production of exuberant or luxuriant callus. 

When the parallel bones of a part are fractured about the same loca- 
tion the resulting callus may produce a bridge, causing synostosis of the 
two bones. When fractures involve joint surfaces, exuberant callus 
generally results, unless perfect anatomical apposition is made, and anky- 
losis may thus take place. 

In articular fractures the fragments are displaced by the effusion 
into the joints, by the violence causing the fracture, and by the pull of 
certain muscles. In this class of fractures union occurs entirely from 
the myelogenic and intermediate callus, as there is no periosteum covering 
an articular surface. Unless accurate apposition of the fragments is 
obtained, there is generally a production of exuberant callus. This may 
interfere with normal joint motion by changing the contour of the joint 
surfaces and thus limiting motion. 

In epiphyseal separation repair proceeds in the same manner as in 
fractures. There is, however, very little callus formed, and as a gen- 
eral rule little if any interference with the epiphyseal cartilage. Sub- 
sequently early ossification of this cartilage may materially interfere 
with the growth of the bone. This condition is rarely seen. 

Repair in Recent Opex Fractures. — The process of repair in 
open fractures is the same as in closed fractures, if there is no infection 
and the fracture is soon converted into a closed one. When infection 
takes place the process of repair is greatly prolonged, and in some cases 
occurs only after great destruction of bone. There are many stages 
to the process, depending upon the nature of the infection and whether 
the periosteum alone is involved, or the medullary cavity also infected. 



GENERAL CONSIDERATIONS 27 

If only the periosteum is involved in septic infection, osteogenic function 
depends entirely upon the bone and endosteum. Generally when an open 
fracture becomes infected there are the early stages of polynuclear infiltra- 
tion and phagocytosis, after which callus formation takes place, accom- 
panied by the discharge of particles of necrotic bone until subsequent heal- 
ing occurs. In these cases the callus is more extensive and its various 
stages of ossification are greatly prolonged. 

Repair in recent aseptic closed fractures treated by aseptic operation 
is identical with the stages seen in closed fractures not operated upon. 
The only difference is that probably the time of repair is somewhat 
lengthened, and at times the foreign bodies used in direct fixation of the 
fragments cause some irritation of the wound. This produces a dis- 
charging sinus from the seat of fracture, with resulting localized caries. 
Removal of the plate or other means of fixation is, as a rule, promptly 
followed by closure of the wound. In fractures subjected to direct 
fixation requiring removal of a non-absorbable means of fixation, there is 
often some degree of infection present. The infecting agent has gained 
admission to the wound at the time of the operation, or subsequently 
through the stitch holes, or perhaps from the blood current, because the 
site of fracture is a place of lowered resistance. 

Delayed Union, Non-union, Vicious Union. — The length of time 
for union to take place varies with different bones, and at different 
periods of life. Union takes place in the phalanges and metacarpals in 
about two to three weeks; about three to four weeks in fractures of the 
ribs and bones of the forearm; five to six weeks for fractures of the 
humerus and bones of the leg; seven to ten weeks for fractures of the 
femur. Fractures of the neck of the femur take even longer. While we 
generally consider that union is firm in these bones in the time specified, 
the Rontgen ray has shown that the reparative process is not complete 
for a much longer time. Repair takes place more rapidly in children and 
the healthy than in the aged and infirm. Even at the end of the times 
mentioned the union is not firm enough to bear unusual stress or strain. 
This is particularly true as to the weight bearing of the lower extremities. 

Delayed Union. — A fracture is classed as one of delayed union 
when there remains any degree of mobility and pain on motion after the 
usual time for consolidation has elapsed. Delayed union is generally 
the result of deteriorated health, and consolidation as a rule is secured 
by improving the general health and increasing local congestion by elastic 
compression, the dependent position and hot-water soaking and massage. 

Non-union. — A fracture is classified as ununited when the rigidity 
of union has not resulted after the usual means have been employed to 
obtain union for a much longer time than is customarily needed. It is 
rather rare; and occurs in the presence of definite bone disease, such as 
necrosis, sarcoma, osteomalacia and carcinoma, when the fragments are 
not in good apposition, or where the patient's general condition is so 



28 TREATISE OX FRACTURES 

weakened that callus formation has not occurred. Failure of union may 
also be due to the interposition of soft parts, to poor blood supply, to infec- 
tion, and to wide separation of the fragments, as in some fractures of 
the olecranon and patella, faulty immobilization, and muscular action. 
A fibrous union is the general sequence of such conditions. The ends 




Fig. 21. — Rontgenogram showing pseudoarthrosis of radius and ulna (see Fig. 22). 

of the fragments are found to be rounded, the medullary cavity is closed, 
and a moderate degree of exuberant callus and fibrous tissue surround 
the area of the ends of the fragments. This condition is known as 
pseudarthrosis (Figs. 21 and 22). True joint formation is rare at the 
seat of an old fracture ; but sometimes a serous bursa is developed between 



Fig. 22. — Photograph of false joint or pseudarthrosis following open fracture of radius and ulna, 
operated upon twice (see Fig. 21). 

the fragments. The most frequent seats of non-union are the shafts of 
the humerus and femur, the patella, the olecranon, and the neck of 
the femur. 

Vicious Union (Fig. 23). — This term is used to describe union 
of fragments in marked deformity. The deformity may be shortening 
from impaction and overriding; shortening combined with rotation of 
the distal fragment; angularity at the seat of fracture; limitation of 



GEXEBAL CONSIDERATIONS 29 

motion due to exuberant callus and changes in the normal relation of 
the joint surfaces. The term is also used to designate that union which 
takes place with the formation of exuberant callus and the inclusion in 
the callus of nerves, blood-vessels, muscles and tendons. The causes of 
vicious union are imperfect reduction of the fracture and imperfect or 
faulty methods of immobilization of the fragments. Vicious union is 
seen most frequently in fractures of the clavicle, of the lower end of the 
humerus, of the lower end of the radius, of the upper end, shaft, and lower 
end of the femur, of the shaft of the tibia, and in fractures about 
the ankle-joint. 

Complications of Fractures. — The complications of fractures may be 
classified under the following headings : 

i. Lesions of the Overlying Soft Parts. — These consist of con- 
tusions, lacerations, perforations by sharp fragments, and sloughing; 
bullae and blebs and, occasionally, gangrene from pressure of subfascial 




Fig. 23. — Vicious union. Femur, fracture of shaft, junction of middle and lower thirds. Union has 
occurred with marked overriding, angulation, and outward rotation of the lower fragment. (Wistar 

Institute of Anatomy.) 

bleeding, exudate or of fragments. Later, as sequels of a fracture, there 
may be disturbances of nutrition shown by interference with the growth 
of the nails and hair, and the occurrence of eczema or other trophic 
changes in the skin. Gangrene or Volkmann's ischemic contracture is 
not due so often to the fracture as to too tight dressings or badly fitting 
splint pressure. Trophic changes, such as distal contractures, palsy and 
ulcers, may be due to nerve compression by constriction of bandaging. 
The commonest complication of fractures is local contamination from 
earth, cutaneous excretions, soiled clothing and applications made in 
first-aid dressings, through which microorganisms have been admitted to 
the wounded bone. This often occurs when the skin is wounded. 

2. Injury to Important Arteries and Veins. — These may com- 
plicate either a closed or an open fracture. The vessels are injured by 
pressure, by laceration, or by puncture. This complication is rare, and 
when it does occur is very serious. The fractures most frequently seen 
complicated by injury to arteries and veins are those of the skull (middle 
meningeal artery), the clavicle (subclavian artery or vein), the humerus 
(brachial or axillary artery or vein), ribs (intercostal artery"), innominate 



30 



TEEATISE OX FRACTURES 



bone (internal iliac artery or vein), femur (femoral or popliteal vessels), 
and tibia (anterior tibial artery). The results of injuries to arteries or 
veins are marked and even fatal hemorrhage, when the bleeding occurs 
into a large cavity; and great extravasation of blood causing gangrene 
perhaps from interstitial pressure, when the blood escapes into the tissues 
surrounding the wounded vessel. 

The symptoms of internal hemorrhage are rapidly increasing anaemia, 
rapid weak pulse, failing blood-pressure, pallor of the skin, thirst, sighing 
respiration, restlessness, collapse, and the physical signs of an abnormal 
accumulation of fluid in a cavity. 

The symptoms caused by a massive extravasation, the so-called false 
aneurism, are a swelling, gradually increasing in size, which later may 





Fig. 24. — Rontgenogram showing diacondylar fracture of humerus (see Fig. 25). 

pulsate, feebleness or absence cf pulsation in the vessel distal to the injury, 
with coldness and anaemia of the extremity, and the presence of a murmur 
synchronous with the pulse. Laceration or puncture of a vein results in 
extensive ecchymosis and swelling, which later may, by compression of 
the vein, produce gangrene of the extremity below. Laceration of both 
artery and vein results in absence of pulse below, marked oedema of the 
part, dilatation of the superficial vessels, and signs of a large hematoma 
or gangrene may occur. 

The treatment of laceration or puncture of important arteries or veins 
consists in immediate exposure of the injured vessel under aseptic pre- 
cautions, ligation of the vessel on both sides of the wound and evacuation 
of blood clots. Resection with end-to-end suture of the two parts of the 
injured artery or vein may be attempted in some cases. The circulation 
should be controlled in the limb by applying a wide rubber bandage above 



GENERAL CONSIDERATIONS 



31 



the site of the suspected tear in the artery, before the search for the 
wound in the blood-vessel is begun. In some cases, it may be necessary 
to ligate the main trunk above the seat of traumatic bleeding, or, if the 
laceration is small, to suture the opening of the vessel. In dangerous 
pressure from blood or exudate without injury to a large vessel wall, 
immediate incisions of skin and deep fascia may prevent the occurrence of 
gangrene or vascular thrombosis from the interstitial pressure. If throm- 
bosis has already occurred, the vessel should be opened, the clot removed, 
and the opening in the vessel wall closed with suture. If the thrombus 
is attached to an area of damaged vessel wall, this should be resected, 




Fig. 25. — Moist gangrene of hand and part of forearm due to diacondylar fracture of humerus, causing 
injury to brachial artery. Case required amputation (see Fig. 24). (Courtesy of Dr. M. M. Franklin.) 



if possible, and ligatures applied on both sides of the gap or the ends 
approximated by anastomosis. The fragments of bone in most of these 
cases should be fixed in apposition, if possible, by a steel plate or other 
device for preventing motion. 

3. Injuries to Important Nerves. — Recent injuries tonerves com- 
plicating fractures are contusion, stretching, compression, laceration, and 
complete division. Late nerve lesions result from compression between 
fragments of bone, or inclusion in callus or cicatricial tissue. 

The fractures in which nerve injury is most frequent are those of 
the clavicle (brachial plexus), humerus (musculospiral, circumflex, and 
median), lower end of humerus (ulnar), radius (radial), femur (sciatic), 
tibia and fibula (peroneal). The symptoms of nerve injury are loss of 



32 



TREATISE OX FRACTURES 



power, loss of sensation, trophic and vasomotor changes, and changes 
in electrical reaction. The late symptoms are muscular wasting, cica- 
trices from trophic ulcers, contractures, and the presence of a neuroma at 
the end of the severed nerve. 

The treatment of nerve injuries associated with fractures consists 
in exposure of the ends of the severed nerve and their union by suture 




Fig. 26c. — Ischasmic muscular atrophy (Volkmann's contracture). (Courtesy of 
Dr. G. G. Davis.) 

with silk. It may be advisable to surround the site of nerve suture with a 
tube of a freshly excised vein. In cases where the nerve is inclosed by 
callus or compressed between fragments, the callus or bone should be cut 
away until the nerve is freed from pressure. 

4. Injury to the Muscular System. — The muscles of the part in 
which a fracture has occurred primarily undergo cedema and later atrophy 
from disuse. This condition rapidly disappears in the young with sub- 




Fig. 26b. — After operation. (Courtesy of Dr. G. G. Davis.) (See Fig. 26a.) 

sequent use, but it may be more or less permanent in the aged or in those 
fractures in which functional mobility is impaired. The coincident dam- 
age to muscles, tendons, and fascial sheaths in all fractures is often 
neglected by surgeons. It may be of as much importance as the lesion 
of the bone itself. Atrophy, adhesions, and loss of function may result 
from the damage to the muscular structures. Massage from the begin- 
ning of treatment may be of great value. The early massage must be 
light. Early mobilization is often valuable. 



GEXERAL CONSIDERATIONS 



33 



A most important secondary complication of fracture is the change 
which occasionally takes place in the muscles of the part, called Volk- 
mann's contracture (Figs. 26, 2J and 28). This condition is probably 
an ischaemic muscular or neural atrophy and is most frequently seen 
involving the forearm, after fractures of the humerus, or of the radius 
or ulna. The change is a dense infiltration of the muscles, followed 
quickly by a rapid degeneration of the muscle fibres, which is irregular in 
distribution. Associated changes occur in the nerves of the part, which 
are found to be degenerated. The cause of the condition is perhaps 



Fig. 27. 



Fig. 28. 




Fig. 27. — Before operation. Ischaemic muscular atrophy (ischaemic myositis). 
Fig. 28. — After operation. (Courtesy of Dr. G. G. Davis.) 



usually undue constriction and interference with the circulation, resulting 
from a too tight application of splints, perhaps improperly padded, too 
tight bandaging, or to the prolonged use of the tourniquet. The symp- 
toms are primary swelling of the part distal to the fracture, with marked 
cyanosis and flexion of the fingers without any great pain. Removal 
of the splints in twenty-four hours may show localized beginning of skin 
necrosis from the pressure on the flexor and extensor surfaces of the 
forearm and the wrist. Marked contracture of the muscles slowly takes 
place with involvement of tendons and nerves, so that the final picture 
is one of marked atrophy and shortening of the muscles, contractures, loss 
of sensation at times, and loss of muscular power. Flexion at the wrist 
3 



34 TEEATISE OX FRACTUBES 

and at the phalangeal joints is marked. The preventive treatment of this 
condition is early removal of all constriction, with massage of the limb. 
Surgeons should be on the lookout for this serious impairment. It 
may arise from early or late excessive bandage pressure or a too tightly 
applied plaster-of-Paris encasement. Threatened gangrene from tight 
dressings gives very marked symptoms; but the condition now being 

Fig. 29c. Fig. 29b. 






Fig. 29a. — Anterior view. Fig. 296. — Lateral view. Two-year-oid deformity from fracture 
of lower end of humerus in child now five years of age. Marked " gunstock " deviation at 
elbow (cubitus varus), due to change in plane of articular surface of humerus. This deviation 
the result of fracture displacement of internal condyle and perhaps to injury to epiphyseal 
plate causing impairment of growth on ulnar side of humerus. 

considered results from a much less degree of constriction. The patient 
complains of only moderate pain, or perhaps scarcely complains at all. 
There may be no marked swelling of the fingers or toes; perhaps only a 
little numbness mentioned. The beginning flexion of the fingers or 
wrist or a deviation in the foot at the ankle may be scarcely observed 
by the surgeon. He will therefore omit removing the retentive fracture 
dressing or may reapply it with the same dangerous degree of pressure. 
The slowness of the process, compared with that which occurs in pressure 
gangrene, and the complaint of only moderate pain are what fail to 



GEXEEAL CONSIDERATIONS 35 

awake suspicion of nurse or doctor that the blood is denied sufficient 
inflow to muscles and nerves. When the constriction is discontinued 
and the limb examined after the lapse of a few days, rigid contracture 
of one group of muscles has overpowered the opposing paretic group. 
The accompanying pallor of the hand or foot, the trophic ulcers of 
fingers and toes and the impossibility of obtaining full active or passive 
mobility confirm the diagnosis of Volkmann's ischsemic myositis 

(Fig. 33)- 

An alert observer will at once institute suitable means to avert the 
impending calamity of crippling. Absolute freedom from constriction, 
hot-water soaking for hours, baking the limb with dry heat, massage, 
active and passive movements, electric stimulation and the wearing of 
orthopaedic appliances to aid the weak muscles and stretch the contracted 
ones will, after weeks of attentive daily care, lead to relief or even cure. 
The degree of improvement depends upon the early recognition of the 
condition and the faithfulness of the care-taker. Later, these measures 
become unavailing, and the deformity above described results. Opera- 
tive treatment of the disabled limb consists in dissecting out the tendons 
and muscles with lengthening of the same, followed by massage and 
passive motion. Nerve resection and anastomosis of muscles and nerves 
may occasionally be of some benefit. Resection for the purpose of short- 
ening both radius and ulna has been suggested for this condition, but 
its usefulness as an operative procedure is doubtful. Mechanical devices 
are at times necessary to keep the fingers in proper position, and at times 
are useful for maintaining partial function. 

5. Injury to a Neighboring Joint. — At times neighboring joints 
are directly involved in the line of a fracture; and, aside from those 
fractures which involve the articular surface, there is often seen marked 
stiffness and oedema of the neighboring joints when the articular end 
of the bone is not broken. This complication is seen most frequently 
in the infirm, the old, and those with a rheumatic tendency. In fractures 
involving the joint surface, there may result a marked traumatic arthritis, 
with perhaps the formation of excessive callus. There then occurs not 
only stiffness and oedema, but also marked limitation of motion. This 
condition is very often permanent, and greatly limits the subsequent 
usefulness of the part. In many of these cases there is an atrophy of the 
muscles of the limb and a peri-articular oedema with fixation of tendons, 
ligaments, and nerves in fibrous tissue, so that all the soft parts are 
involved in a general cicatrix. 

When the line of fracture involves the adjacent joint, there is 
generally seen a moderate degree of limitation of motion, unless the 
fragments are accurately adjusted ; then callus formation is slight. The 
presence of intra-articular callus formation is due to malapposition 
of the fragments. By the deformity and the deposit of callus, the joint 



3G 



TREATISE OX FRACTURES 



surfaces are altered and the contour of bearing surfaces changed. The 
result can hardly fail to be limitation of motion. 

The treatment of these conditions consists in the accurate adjustment 
of the fragments primarily, persistent active and passive motion, mas- 
sage, and in those cases in which limitation of motion is due to serious 
malposition of fragments, operation. An X-ray examination will fre- 
quently indicate the character of operative intervention needed. 

Association with an Adjacent Dislocation. — At times fracture 




Fig. 30. — Fracture of great tuberosity of humerus. 



may be complicated by a dislocation of an adjacent joint The com- 
bination is seen most frequently in fractures of the surgical neck of the 
humerus associated with dislocation at the shoulder-joint, fracture of 
the glenoid cavity or neck of the scapula with dislocation at the shoulder- 
joint, fracture of the upper end of the ulna associated with dislocation 
of the head of the radius, fracture of the lower end of the radius with 
dislocation of the lower end of the ulna, fracture of the "vertebrae with 
dislocation, fracture of the upper end of the femur with dislocation of its 
head, and fracture of the pelvis associated with dislocation at the hip- 
joint. Epiphyseal separation of the upper end of humerus with dis- 



GENERAL CONSIDERATIONS 37 

placement of the fragments resembles very much dislocation of the 
shoulder- joint in its clinical appearance. Error in diagnosis is not 
unusual unless X-ray plates are secured. 

The treatment of this condition may be non-operative or operative. 
Occasionally it is possible to reduce the dislocation by external manipu- 
lation, either before the fracture has been reduced or after the fragments 
have been replaced and immobilized. Generally, however, it is necessary 
to expose the seat of fracture by incision. Then after reduction and 
immobilization of the fragments, it may be possible to reduce the dis- 
location. At times it is necessary to expose also the seat of dislocation 
in order to obtain reduction. Occasionally excision of the articular 
fragment may be necessary. 

A fracture may be associated with a previously unreduced dislocation 
or an ankylosed joint. When there is present a previously unreduced dis- 
location complicating a recent fracture, the presence of the dislocation 
should be disregarded unless it may seem possible to reduce it and hold 
the parts in their normal position by operation. Generally, the articular 
changes present are of such a character as to preclude the possibility 
of improvement, short of excision of the joint. In fractures compli- 
cated by ankylosis of a neighboring joint it will be most feasible to 
entirely disregard the presence of the ankylosis. It should, however, 
be borne in mind that extra precautions should be taken in immobilization, 
as this condition may be followed by non-union or pseudo-arthrosis at 
the seat of fracture. It is possible that non-union of the broken bone 
might be a benefit to the patient if the fracture is near the articular 
end of the bone. The mobility so obtained might, especially at the 
shoulder, be an advantageous substitute for the immovable anky- 
losed joint. 

Fat Embolism. — This is a condition often described in treatises on 
fractures but is rarely seen, and when it does occur is usually followed 
by no alarming symptoms. It can readily be seen that in all fractures 
involving the bone-marrow there are almost necessarily small numbers of 
fat globules carried into the circulation. These fat globules may find 
their way to the brain, lungs, kidneys, or spleen. They differ, however, 
from the ordinary blood embolism in that the fat globules do not adhere 
to each other, and therefore usually do little harm except in terminal 
vessels of very small calibre. In the various organs where they may lodge 
they may produce infarcts, cedema, or, in the lung, pneumonic areas. 

It is more common in closed than in open fractures, and may sometimes 
give rise to grave symptoms. In the brain fat globules may produce 
areas of cerebral softening. In the lung they may cause dyspnoea, 
cyanosis, and areas of dulness with rales; in the kidneys they may pro- 
duce fat globules in the urine, with casts and albuminuria. 

The treatment of the condition is entirely symptomatic. While the 
presence of fat globules in the circulation in cases of fracture is common, 



38 TEEATISE OX FRACTURES 

the fact of their producing any actual damage is questionable, and the 
cases of supposed death in cases of fracture, commonly ascribed to fat 
emboli, are very doubtful and open to question. A thorough autopsy on 
these cases would undoubtedly frequently show the cause of death to be 
other than fat emboli. Fat embolism has been given as a pathological 
cause of symptoms of surgical shock, after the crushing fractures seen in 
military service. This etiology has, however, been refuted by what is 
believed to be competent testimony. 

Thrombosis and Embolism. — In fractures of the lower extremity 
all the evidences of obstruction to the venous system may appear. This 
is particularly true in fractures of the bones of the leg, and is due to 
the formation of a thrombus, generally in the deep veins. This condition 
is rarely seen while the patient is at rest in bed, but may occur when the 
patient begins to be up and about. Then is seen a large, cedematous, 
bluish leg, resulting from obstruction. In some instances emboli are 
detached from the venous thrombus ; and are carried through the heart 
to the lungs and there produce lesions varying from a localized bronchitis, 
or localized consolidation with pleurisy, to sudden death. The symptoms 
of these conditions occur, as a rule, several weeks after the injury, and 
sometimes after massage of the part. The onset is prompt and in cases 
of sudden death there may be extensive pallor or cyanosis, difficulty 
in breathing, shock, a weak, rapid pulse, and a rapidly fatal issue. It 
is very suggestive of this condition when patients develop the so-called 
hypostatic pneumonias in cases of fracture. In such instances it is always 
well to consider the possibility of pulmonary emboli. Thirty-six cases 
of pulmonary embolism after fracture are reported by Lotheissen, with 
30 deaths. They all occurred in people past middle life, and 34 cases were 
closed fractures. The bones of the leg were fractured in 25 cases, the 
femur in 7 cases, the humerus in 3 cases and the patella in 1 case. Two 
cases were open, or compound, fractures. Thrombosis is relatively rare 
after fracture. The usual blueness and swelling of the foot and leg, 
which are shown, when patients first get up on crutches, is merely a 
capillary congestion favored by gravity, the dependent posture of the limb, 
and the lack of tone in the vessels and tissues from restraint of motion 
during treatment. Frequent removal of the dressings, friction of the 
skin, light massage, and hot-water soaking will soon restore vascular tone. 

The preventive treatment of this condition is care in the splinting of 
the parts, careful massage and passive motion with proper stimulation 
to the arterial system. In embolism the treatment is purely symptomatic. 
Extensive pulmonic embolism is generally fatal. 

Infection. — This condition is seen most frequently as a complication 
of open fractures. It is rarely seen in closed fractures. When it occurs 
in closed fractures the patients are apt to be children ; and the lesion begins 
generally in the epiphyseal end of the diaphysis. It occurs here through 
deposit of bacteria in the terminal vessels at the epiphyseal line, and in 



GENERAL CONSIDERATIONS 39 

addition to the symptoms of a fracture there arise symptoms of an 
acute osteomyelitis. 

Infection of the seat of fracture may arise in several conditions. In 
closed fractures infection may occur through the blood stream. In- 
fection occurring in this manner is generally in fractures at the lower 
ends of the bones or near the epiphyseal line, and is due to the lodgment 
of bacteria in the terminal vessels at this point. The condition is 
rare, and sometimes occurs and presents all the symptoms of an acute 
osteomyelitis in addition to those of fracture. Diagnosis is difficult, 
and one should not be too hasty in making a positive diagnosis. In 
addition to the local signs, there is marked elevation of temperature, 
leucocytosis, and a marked increase in the polymorphonuclear percentage. 

Primary infection may take place at the seat of fracture through 
wounds of soft parts overlying the fracture. If the wound leads down to 
the site of fracture the injury is called an open fracture. In open fractures 
infection occurs generally at the time of injury. Secondary infection 
may occur from sloughing of the soft tissues overlying a closed fracture. 
Infection also may occur in closed fractures through an operation wound 
made in applying a direct fixation apparatus. 

The organisms found are, as a rule, the Streptococcus pyogenes, the 
Staphylococcus aureus or albus, or a combined infection of the two. 
Occasionally a more virulent form of infection is seen. Of these may 
be mentioned the tetanus bacilli, the Bacillus aerogenes capsulatus. the 
bacillus of malignant cedema. In all cases of infection the severity of 
the local signs depends upon the nature of the organism, the extent and 
character of the wound, and the general powers of resistance. The chief 
symptoms are redness, cedema, and increased local heat, with the presence 
of a foul discharge from the wound, in addition to the general symptoms 
of infection, vis., increase in temperature, increased pulse rate, leucocy- 
tosis, and delirium. In the malignant forms of infection the symptoms 
are more severe. Rapid and extensive involvement of the affected bone 
occurs, and at times of the neighboring joints. Gangrene is rapid and 
sapraemia and septicaemia very pronounced. 

The treatment is antisepsis, and extensive drainage at the seat of 
fracture, by means of free and multiple incisions, combined with general 
supportive treatment. Amputation is not an unusual necessity, when 
this active surgical management is omitted or delayed. The European War 
has taught that infection of contaminated wounds of soft parts and of 
bones may be averted by early and thorough removal of foreign bodies and 
the excision with sterilized instruments and hands of all contused, lacer- 
ated and partially devitalized muscles and pulpefied bone fragments. This 
radical treatment, if thoroughly carried out within eight or ten hours, 
will probably permit immediate or quite early closure of the wound and 
rapid union of the fracture. The technic of this early surgical operative 
procedure under anaesthesia has been developed by militarv surgeons in 



40 TREATISE OX FRACTURES 

the treatment of gunshot fractures. It is valuable also for open fractures 
in industrial and other fractures of civil life. 

Shock axd Hemorrhage. — These two conditions are occasionally 
found complicating severe fractures. They are seen most frequently 
in fractures of the skull, ribs, pelvis, and femur. The two conditions 
are very often characterized by similar symptoms, but they should be 
differentiated. Shock is seen most frequently in multiple fractures accom- 
panied by considerable bruising of the soft parts, and in patients who 
have been transported for a considerable distance. Hemorrhage is seen 
especially in fractures near large vessels and in those which communicate 
with visceral cavities, into which extensive hemorrhage may occur with- 
out external evidence. In both blood-pressure is low. 

Treatment of shock should consist in prompt immobilization of the 
fragments, the supine posture with the pelvis and lower extremities 
elevated, general stimulation, the application of external heat, and the use 
of morphia and remedies applicable to shock from other injuries. 

In cases of suspected, concealed, or internal hemorrhage it may be 
necessary to expose the seat of fracture and ligate the bleeding vessel, 
especially if the hemorrhage is extensive and endangering the life 
of the patient. 

Traumatic Delirium. — This symptom complex occasionally is seen 
as a complication of fractures in the young and those who are not 
addicted to the use of alcohol. The condition occurs generally in 
persons who have been under considerable mental stress for years, and 
is similar in character to post-operative delirium. The chief symptoms 
are low, muttering delirium without fever. The patient's attention can 
at times be fixed, only to be quickly lost ; the events. of the past are recalled, 
and the subject causing mental anxiety is uppermost in the patient's mind. 
Refusal to take food, relaxation of the sphincters, and rapid emaciation 
are also symptoms occasionally seen. 

The treatment of traumatic delirium is forced feeding, watching the 
excretions, care of the dependent parts of the body so as to prevent 
bed-sores, and the use of a general tonic. The prognosis in this form 
of delirium is usually good, but at times death follows. It is not as 
dangerous a complication in fractures as is alcoholic delirium. 

Alcoholic Delirium. — Traumatic delirium tremens is an occasional 
complication of fractures, especially infected fractures, in persons whose 
nervous systems have undergone, prior to injury, the deterioration due 
to the habitual use of alcohol. It is possible that a similar deterioration 
of tissues and a consequent liability to a trembling delirium may arise 
from habituation of opium, chloral and tobacco. Patients may develop, 
under the influence of surgical shock, hemorrhage and anxiety, a nervous 
delirium similar to the trembling delirium of alcoholics, although their 
habits have included only a moderate but continued consumption of alco- 
hol. The surgeon should suspect an alcoholic history, even of only 



GEXEEAL COXSIDEEATIOXS 41 

moderate "tippling," if those who have sustained serious fracture com- 
plain of sleeplessness at night and show restlessness, or even slight 
tremor of the hands. The sudden withdrawal of alcohol or tobacco re- 
sultant upon confinement in bed or in unusual surroundings due to the 
fracture may develop delirium tremens. The complication is a grave 
menace to a proper care of the fracture. 

The initiatory symptoms are sleeplessness at night and slight tremor. 
The latter can be best shown by asking the invalid to hold out the hand 
with widely-extended fingers. Occasionally the onset may be sudden 
and unexpected by the attendants. Subsequently restlessness, sleepless- 
ness and tremors increase, and delirium is shown. The delirium is often 
first shown at night and is peculiar. The patient sees mice, insects or 
snakes creeping upon him or in the bed, or is pursued by some hideous 
spectre. He constantly tries to escape from these tormentors. He may 
jump out of bed or a window to escape persecution. His mental con- 
dition is one of depression, fear and great activity. He chatters in a low 
tone, and may cry out in fear, but does not show maniacal excitement. 
He is good-natured and not inclined to do violence. He may be aroused 
by emphatic words to an understanding of his surroundings, but soon 
relapses into incessant garrulity and motion. The muscular tremor is 
not like the twitching of tendons in asthenia, but is a shaking similar 
to that of cerebrospinal sclerosis. Sometimes there is hurry and the 
limbs or tongue may be thrust out with a jerk. Unconsciousness and 
death may occur. The restlessness, motions and fear render it difficult to 
keep fracture dressings in place. Resort to gypsum encasements may be 
a necessary part of the restraint of the limb, because the patient insists on 
pulling off the splint or tries to walk about the room with fracture box 
or traction apparatus dragging after his feet. Restraint with sheets, 
a strait- jacket or uninterrupted w r atching may become absolutely essen- 
tial to prevent injury by jumping out of a window. 

Successful treatment depends on early recognition and diagnosis 
of the patient's impending delirium, avoidance of the belief that his will- 
ful disobedience of orders is an exhibition of stubborn temper, and suffi- 
cient nutrition, sleep and stimulation to sustain the flagging energies. 
The opinion is probably correct that alcohol in moderate, but decreasing, 
doses given with milk is a valuable adjuvant to feeding and medicinal 
treatment. Sleep usually means the beginning of improvement. 

Hypostatic pneumonia and pressure sores on the back, heels, buttocks, 
hips and shoulders are to be averted by alert supervision and care. 

Pulmonary Complications. — Pneumonia as a complication of 
fractures in the aged and debilitated is not frequently seen, but it may 
develop during the period of treatment. Its cause is not known, but 
the occurrence of fat emboli may have something to do with its onset. 
As a rule it is not preceded by a chill ; the course of the disease is rapid. 



42 TEEATISE OX FRACTURES 

It is generally lobar in type, is accompanied by high fever and muttering 
delirium, and a fatal result may occur within a few days. 

Another form of lung complication is perhaps more frequent than 
the lobar pneumonia above described. It is a bilateral hypostatic in- 
volvement of the posterior aspect of the lungs, and is seen most frequently 
in those of advanced life. Its onset is gradual, there is no chill, and only 
moderate fever. The course of the disease is slow and fatal in many 
cases. The condition is favored by long recumbency in one position. 
Pathologically, it consists of extensive venous congestion of the lower 
lobes, and it is a very frequent indication of failure of the heart and 
general decline in the vital functions. 

The treatment consists in turning the patient frequently or otherwise 
changing his position, massage, and general stimulation. The prognosis 
of this condition is very bad. 

Bronchitis is another pulmonary complication of fractures. It is seen 
most frequently in the aged, as a coincident disease with various forms 
of delirium, and may be caused by failing cardiac power or as the result 
of inspiration of particles of food. It is generally a diffuse condition, 
more pronounced posteriorly than anteriorly, and is progressive in charac- 
ter, generally ending in a lobular pneumonia which is fatal in a short 
time. Its treatment is purely symptomatic. 

Cardiovascular Changes. — These consist in disease of the heart 
muscle, which undergoes fatty degeneration, and pathologic alteration in 
the coronary vessels. There may be no signal evidence of myocardial 
or coronary disease while the patient lies in bed. It becomes evident 
after he is released from bed; and is characterized by precordial distress, 
dyspnoea, cyanosis, and later by failing compensation, and occasionally 
by sudden death. Sometimes the symptoms are incorrectly classified as 
pulmonary embolism. Post-mortem examination reveals no evidence of 
pulmonary emboli, but the heart shows an increase of fat in the epicar- 
dium. The heart muscle is yellowish brown, friable and soft, and the 
coronary arteries are atheromatous. 

The treatment in those cases which are not rapidly fatal is rest, mental 
and physical, cardiovascular remedies, and later moderate exercise and 
bathing. The surgeon should -be guided by frequent blood-pressure 
observations. 

Prognosis. — The prognosis after fractures is dependent upon many 
factors. It is a common mistake to imagine that perfect function will 
be present as soon as union is firm. The prognosis will depend upon the 
age of the patient, the variety, nature, and site of the injury, the character 
of the violence, the presence of changes in alignment and weight bearing, 
the future stress on joints due to poor anatomical apposition of the 
fragments, and to the occurrence of complications. The prognosis is 
greatly modified by the surgeon's neglect or care of the soft parts in the 
vicinity of the fracture. Frictions, light massage, and early attention to 



GENERAL CONSIDERATIONS 43 

the joints and muscles are often as important as reduction of the frag- 
ments and their fixation. 

Fractures unite more rapidly in children than in adults. The deformi- 
ties in bony outlines following fractures in children generally tend to 
grow less and the functional results improve as the patient grows older. 
F. Konig and also Birt have shown this conclusively. While this is true 
in many cases, it is also true that many deformities are not only disfigur- 
ing, but may increase and ultimately interfere with the function of 
extremities and their movements at joints. A good example of this is 
traumatic coxa vara occurring in the neck of the femur of the young. The 
deformities due to improper reduction, while they are not as difficult to 
correct in children as in adults, are very troublesome. Surgeons should 
endeavor to obtain perfect approximation of the fragments at the time 
of the injury. 

Bevond middle life the prognosis of fractures is less favorable. In 
advanced life it is frequently poor. This is due to several factors. The 
principal ones are the rarefying process which takes place in bones in 
advanced life, the difficulty of giving proper care to these patients, and 
an increased liability to traumatic delirium, alcoholic delirium, hypostatic 
pneumonia, and cardiac degeneration. In these instances much depends 
upon the good judgment of the surgeon as to the wisest local treatment of 
the lesions in bone and soft parts. Routine methods may work harm. 

Fractures which are closed and uncomplicated are usually followed 
by good functional results if the treatment is mechanically and physiologi- 
cally wise. Open fractures are more liable to infection, necrosis, shorten- 
ing, and deformity. Fractures which are oblique or spiral are usually 
difficult to retain in proper position and are therefore followed more 
frequently by shortening, or rotary or angular deformity. Fractures in 
which the line of facture is transverse generally remain in good position 
w T hen carefully reduced, and if this reduction is maintained the anatomical 
and functional results are good. Fractures involving joints or in close 
proximity to joints are not infrequently followed by partial limitation of 
the normal motions of the joint. Examples of this are fractures about 
the elbow and ankle-joints. Fracture of one of parallel long bones is 
generally followed by a good result, because the sound bone acts as'a splint 
and preserves the longitudinal alignment. This, however, is not always 
the case, as is seen in spiral and oblique fractures of the tibia. Fractures 
of the spongy bones are usually followed by some deformity, owing to 
the crushing and comminution of the fragments. Breaks of the small 
bones unite sooner than fractures of the large bones. Fractures will 
sometimes be followed by imperfect anatomical and functional results, 
notwithstanding repeated efforts at perfect reduction and approximation 
and expert supervision. 

Changes in the soft parts and of the neighboring joints may influence 
the prognosis. Stiffness of the articulations, adhesions about joints, 



44 TEEATISE OX FRACTURES 

(Edema and congestion of the parts, which are increased when the de- 
pendent position is assumed, and pain aggravated by changes in the 
weather are some of the common sequelae of fractures. These changes 
may require months for their eradication, and in some cases are perma- 
nent. It is practically certain that, to a considerable degree, stiffness 
of joints, adhesions of tendons, oedema, and pain may be averted if, in 
addition to reduction and mechanical support, fractures are treated early 
with frictions, light massage, and passive motions. Active movements 
by the patient begun early in the treatment of joint fractures has been 
earnestly advocated by Willems. Infected gunshot fractures of the 
large joints are advised by him to be subjected to prompt' sterilization. 
This is followed by insistent instruction to the patient that fear of pain 
must not be permitted to interfere with early active movements at the 
joint. Ankylosis is thus greatly eliminated. Changes in the soft parts 
about the fracture may greatly lessen the good functional results which 
should be otherwise obtainable. Stiffening of neighboring joints is gener- 
ally due to simultaneous involvement of the joint structures in a sprain, 
to hemorrhagic extravasation around or into the synovial sac, to involve- 
ment of tendons in ossifying callus, to the contraction of peri-articular 
tissues and ligaments during the time of immobilization, and to the de- 
velopment of excessive callus about the joint surfaces. This stiffness is 
most marked and most persistent in the aged and in those subject to 
rheumatoid arthritis. CEdema is the result of pressure upon deep veins 
by fragments of bone or callus or the development of a phlebitis resulting 
from the deposit of fibrin about the seat of fracture. Protracted immobil- 
ization of fractures in splints, infrequent examination and neglect of the 
care of the skin and muscles during the wearing of the splints are un- 
doubtedly responsible for many of these sequelae. Attention to the soft 
parts in the manner advocated by Lucas-Championniere and his followers 
will obviate many of these difficulties. 

General Statistics 

There are so many elements entering into the prognosis of fractures 
that it is difficult to give general statistics that will cover all forms. 
Each case must be considered on individual grounds; and fractures occur- 
ring in the same bone must be grouped in specified classes. Statistics 
even then are at times of little use in forming an opinion of an individ- 
ual fracture. 

General statistics and statistics of individual fractures of the long 
bones were published in November, 19 12. by a Committee of the British 
Medical Association appointed to report on the ultimate results obtained 
in the treatment of simple fractures with or without operation. The Com- 
mittee limited its inquiry to closed fractures of the long bones which 
occurred or in which operations had been performed in the period 
January, 1906, to December. 19 10, inclusive. This period was selected 



GEXERAL CONSIDERATIONS 45 

so that six months should have elapsed since the commencement of the 
treatment. During the period mentioned there were treated in 15 hos- 
pitals 11,946 fractures of the long bones non-operatively, with a fatal 
result in 129 cases, a mortality of 1.0 per cent. ; the majority of the deaths 
due either to age, disease or associated injuries. Of the 1040 cases 
treated by operation, there was a fatal result in 8 cases, a mortality 
rate of 0.77 per cent. Of these 8 cases there were 3 cases in which the 
cause of death was existing organic disease, and 2 were directly due to 
the anaesthetic. The other 3 cases were directly attributable to the opera- 
tion. These were due to septicaemia (2 cases) and sepsis (1 case). The 
ratio of the non-operative patients to the operative was about ii J / 2 to 1. 
The fatalities, therefore, in an equivalent number of patients operated 
upon would have been 11V2 times 5, or 57^. A death-rate of S7 l A 
patients in 1 1 ,946 cases treated by non-blood-shedding methods by men 
as skilled in the methods as were the men doing the operations tabulated, 
would be terrifying. As the total fatalities in the Committee's collection 
of non-operative cases were only 129, or 1 per cent., including deaths 
from all causes and associated injuries, it is evident that the mortality 
in 1040 operative cases, which would be 57.5 per cent, in 11,946 cases, 
is too high to meet with approval of the operative treatment, advised 
by Sir Arbuthnot Lane, as a routine management for fractures of the 
long bones. 

The Committee examined personally 2948 patients, and with those in 
which there was a fatal result during treatment, a total of 3062 cases were 
investigated. No cases of open (compound) fractures were studied 
by the Committee. 

The Committee separated the non-operative cases from the opera- 
tive cases. In the non-operative cases all forms of treatment were used. 
In the operative cases three classes were distinguished : Those cases in 
which operation was decided upon at once and performed as soon as 
practicable (Class A). Those in which operation was performed on 
account of failure to obtain and maintain accurate apposition by means 
of external mechanical appliances (Class B). Those cases in which 
operation was performed for non-union, for deficient union, or for faulty 
union whether in progress or when complete (Class C). 

An analysis of all results, non-operative and operative, clearly showed 
the interdependence of the anatomical and functional result. The total 
number of cases in which a good anatomical result was obtained was 1736, 
and in no less than 1576 of these the functional result was also good. 
In other words: " If the anatomical result be good the functional result 
is good in 90.7 per cent. If the anatomical result be moderate or bad, 
the functional result is good in 380 out of 1279 — i.e., 2g.y per cent. If 
the anatomical result be bad, the functional is bad in 176 out of 330 — 
i- e -> 53-3 per cent." 

A just criticism of this report of the British Fracture Committee is 



46 TREATISE OX FRACTURES 

that no distinction was made between the types of non-operative treat- 
ment or of the varying ability of the practitioner; while in the operative 
class at the date of investigation most of the operations were done by 
expert surgeons, and the operative cases were divided into three classes. 

An attempt was made by the Committee to determine the influence 
of age upon the result of treatment. They found that for all practical 
purposes age groups might be condensed into children (0-15 ), and adult 
life (over 15). Of the non-operative cases there were 10 16 under 15 
years, with a good functional result in 90.8 per cent., and 1580 over 15 
years, with a good functional result in 45.4 per cent. Of the operative 
(Class A), there were 64 cases under 15 years, with good functional 
result in 93.6 per cent., and 83 cases over 15 years, with good functional 
result in 66.3 per cent. 

The Committee determined that the percentage of good functional 
results (disregarding entirely the anatomical results) is smaller with 
each succeeding age group. Their analysis shows that under each age 
group there is a progressive depreciation of the functional result of the 
non-operative treatment as age advances; in other words, the older the 
patient the worse the result. 

The Fracture Committee of the American Surgical Association, 
appointed in 1912, has also prepared statistical tables and recorded opin- 
ions of value. 

In 19 1 3 it agreed with the opinion of the British Committee that the 
operative treatment required such special skill and experience and such 
facilities to prevent sepsis as made the operative method one not to be 
undertaken except by those in constant practice and experience in surgi- 
cal procedures. 

In 191 5 the American Committee reported further that the present- 
day results in subcutaneous (closed) and air-exposed (open), sometimes 
called " compound," fractures, the average time of disability and the 
relative value of non-blood-shedding and blood-shedding methods of 
treatment had been among the points investigated. The British Com- 
mittee had carefully investigated and tabulated 3062 cases in studying non- 
operative and operative treatment. The American Committee tabulated 
1745. Of these there were 1358 non-operative and 387 operated upon; 
258 of the operated cases were subcutaneous (closed) fractures, 129 
air-exposed (open) fractures. 

It found that results are best under 15 years and that treatment with- 
out operation was generally effective in this period of life. This corre- 
sponded pretty well with the result of the British Committee. 

It also determined that good anatomical restitution of a broken long 
bone results in better functional result than imperfect reconstruction, and 
permits a shorter period of disability from ordinary duty; that the final 
result in air-exposed (open) fractures showed very little difference be- 
tween non-operative and operative treatment so far as anatomical result 



GEXEEAL CONSIDERATIONS 47 

was concerned. Functional result was better after operative measures 
except in open fractures of the shafts of both bones, where the reverse 
seemed to be true. 

The average period of disability, i.e., time lost from work, in subcu- 
taneous fractures was as follows in the American Report : 

Fractures, shaft of humerus 14 weeks 

head and neck of humerus 11. 5 " 

at condyles of humerus 9.0 " 

shaft both bones of forearm 10.8 " 

femur all sites j.tf months 

leg all sites 4.75 " 

Dr. W. L. Estes, a member of the American Fracture Committee, gives 
the period of disability in 51 personal patients with open fractures as: 
femur, 13 months; leg, 6 months; upper extremity, 4 months. He does 
not say whether or not these were operated upon. 

It seems unfortunate that the British Committee did not attempt to 
separate the non-operative cases into two classes : those in which the fixa- 
tion by splints was a more or less prolonged immobilization, and those in 
which mobilization with light massage similar to the Lucas-Championniere 
method was adopted. One of us (Roberts) is convinced that the great 
defect in non-operative treatment for years past has been infrequent 
removal of the external fracture dressings. A consequent infrequent 
examination of the position of the fragments and a more or less usual 
neglect of attention to the soft parts by massage and mobilization have 
given rise to bad results. Hence has come the demand for direct fixation 
by metal plates introduced through operative incisions. It seems possible 
that American surgeons have been less attached to prolonged immobiliza- 
tion than the British surgeons; and that on this account they have seen 
a less number of bad anatomical and bad functional results than would 
otherwise have been the case in the non-operative treatment of closed 
fractures. The Continent of Europe has perhaps been more influenced 
than England by the teaching of Lucas-Championniere; namely, that 
prolonged immobilization is a mistake in the non-operative treatment 
of fractures. The report of May, 191 3, of the Fracture Committee of 
the American Surgical Association made similar suggestion. 



CHAPTER II 

EPIPHYSEAL SEPARATIONS 

A traumatic separation of the epiphysis from the shaft is called a 
diastasis and resembles in many of its characteristics a fracture. 

Anatomy. — All bones are formed in the embryo either in membrane, 
or in cartilage covered by membrane. Ossification takes place beneath 
this membrane in all and exclusively in some, as the clavicle. The dia- 
physis or body of the bone has one or more primary centres of ossification. 
The epiphysis has one or several secondary or tertiary centres of ossifi- 
cation, which are united to the diaphyses for a time by epiphyseal cartilage. 
The epiphyses or secondary centres help to form the extremities of the long 
bones or the projecting processes. An apophysis is a prominent projec- 
tion of bone which is not developed from an independent centre of ossifi- 
cation. The primary centres appear in the diaphyses of long bones before 
birth, with several exceptions. The secondary centres in the epiphyses 
appear after birth, with the exception of the upper epiphysis of the tibia, 
the lower epiphysis of the femur, and the upper epiphysis of the humerus. 
The diaphysis is separated from the epiphyses of the long bones by an 
intervening layer of cartilage called the epiphyseal cartilage. Growth 
occurs from the centres in the diaphysis and epiphyses, accompanied 
by a corresponding growth of the epiphyseal cartilage. When the bone 
has attained its full growth, union of the diaphysis and epiphyses takes 
place by ossification of the epiphyseal cartilage. Bones increase in diame- 
ter through deposit of bone from the periosteum. The following rules 
of bony union of the diaphysis and epiphyses have been laid down 
by Gerrish : 

" i. The extremity whose ossific centre is the first to appear is the 
last to unite with the shaft. Exception : the lower end of the fibula, 
probably because the upper end is vestigial. 

" 2. The extremity toward which runs the nutrient artery is the 
first to unite. 

"3. The nutrient arteries run toward the elbow and away from the 
knee, i.e., down hill, if elbow and knee are both flexed. 

" 4. Union of the epiphyses and diaphyses of long bones occurs from 
the sixteenth to the twenty-second year (occasionally twenty-fifth year, 
tibia) and earlier in the upper than in the lower extremity. 

''5. When two or more centres of ossification occur in an epiphysis, 
these unite together before the epiphysis unites with the diaphysis 
or shaft." 

The Date of Ossification of the Epiphyses and the Time of 
Union of the Epiphyses to the Diaphyses. — The mandible is formed 

48 



EPIPHYSEAL SEPARATIONS 49 

mostly in membrane about Meckel's cartilage. There are, however, four 
to six centres of cartilaginous ossification. From the symphysis to the 
mental foramen ossification takes place from Meckel's cartilage; the 
condyles and angles -ossify from separate centres of cartilage. At birth 
two bony halves of the mandible are separated by a fibrous synchondrosis, 
which unite during the first year. The maxilla has five to seven centres 
of ossification. These unite before birth. The premaxillary portion may 
fail to unite with the others in some cases of cleft palate. The nasal bone 
has i or 2 centres appearing about the time at which vertebral centres 
occur in embryonal life. These bones are ossified at birth, as are the 
malar bones, the two centres of which usually coalesce before birth. 

Hyoid or Ungual bone is developed in cartilage ; there is a centre for 
each cornu and for each half of the body. Ossification of the body and 
greater cornu begins before birth, of the lesser cornu at a later period. Os- 
sification of the synchondrosis of the body and greater cornua occurs 
usually after middle life. The synchondrosis of the lesser cornu sel- 
dom ossifies. 

The scapula is preformed in cartilage during fetal life; ossification 
occurs from two primary and five secondary centres. The primary centres 
are on the body and coracoid processes, which unite about the fifteenth 
year. Two centres appear in the acromion at the fifteenth year; these 
unite, and join the spine at the twentieth year. 

The clavicle is preformed in cartilage (prechondral tissue) ; and 
the main centre of ossification appears about the seventh week of em- 
bryonal life. It is the first bone to ossify. An epiphyseal centre appears 
at the sternal end about the fifteenth to eighteenth years and unites with 
the shaft about the twentieth year. 

The sternum is preformed in cartilage; the manubrium is generally 
developed from a single centre, the gladiolus from four to twelve evenly 
divided bilateral centres, and the xiphoid from one centre. Ossification 
of the sternum begins about the fourth to sixth month of fetal life, and 
the xiphoid from the sixth to the twentieth year. Failure of union of the 
two halves may result in a median foramen or vertical fissure. 

The ribs are preformed in cartilage and have a primary centre near 
the angle. Epiphyseal centres appear for the heads and tubercles after 
puberty, and unite with the main portions of the bone about the twenty- 
fifth year. 

Vertebra:. — Each vertebra has three centres of ossification, one for 
the body, and one for each half of the vertebral arch. Ossification begins 
at the end of the second month of embryonal life. Accessory centres 
appear about the age of puberty, at the spinous and transverse processes, 
on the mammillary processes of the lumbar vertebra?, and on the upper 
and lower surfaces of the vertebral bodies. These accessory epiphyses 
unite with the remainder of the vertebra when growth has been com- 
pleted, about the 30th year. Some variation occurs in the atlas and axis. 
4 



50 



TREATISE OX FRACTURES 




Fig. 31. — Epiphyseal lines of upper end of right humerus, and acromial process of scapula. 





Fig. 32. — Epiphyseal lines and centres of lower end of humerus, and upper ends of radius and ulna. 



EPIPHYSEAL SEPARATIONS 51 

The odontoid process unites with the body of the axis during the 
third year. 

The humerus (Figs. 31 and 32) is developed from a centre of ossifica- 
tion for the diaphysis, which appears during the eighth week of fetal life, 
and six or seven secondary centres for the extremities which appear after 
birth, the epiphyses then being cartilaginous. During the early years the 
centres appear in the following order : upper epiphysis for the head, the 
capitellum, the greater tuberosity, the lesser tuberosity, the trochlea, the 
internal and external condyles. Ossification begins, in the internal condyle 
much earlier than in the external condyle. Complete ossification and dis- 
appearance of the synchondroses occur from the twentieth to the twenty- 
second year. 

Radius (Figs. 32 and 33). — The centre for the diaphysis appears 

mt - 







^3f 



Fig. 33. — Epiphyseal lines of lower end of radius, and centres of carpal, metacarpal and 
phalangeal bones of hand. 

in cartilage about the third fetal month, the secondary centre for the 
head appears about the fifth year and unites to the shaft about the 
fifteenth year; and a secondary centre for the lower end appears shortly 
before the upper one, but does not unite with the shaft until the twentieth 
year. Accessory nuclei appear for the tubercle and styloid process. 

Ulna (Figs. 32 and 33). — The centre for the shaft occurs in cartilage 
about the third fetal month. The upper end of the olecranon is ossified 
from a secondary centre for the olecranon and another for the coronoid 
process, which join the shaft about the sixteenth year. There is also a 
secondary centre for the lower epiphysis which forms the styloid process 
and joins the shaft from the eighteenth to the twentieth year. 

Carpal Bones (Fig. 33). — All the carpal bones ossify from a single 
centre and are cartilaginous at birth. The centres for the os magnum 
and unciform appear during the first year; and for the other bones be- 
tween the third to the ninth year, with the exception of the pisiform, 
which does not begin to ossify till the twelfth year. 

The metacarpal bones (Fig. 33) are preformed in cartilage and ossify 



52 



TREATISE OX FRACTURES 



from a diaphyseal centre for the shafts and an epiphyseal centre in the 
head, except the so-called metacarpal bone of the thumb, which has its 
epiphyseal centre in the base like a phalanx. The diaphyseal centres appear 
in the ninth week of fetal life and the epiphyseal centres appear 
after birth. 

Phalanges (Fig. 33). — They are preformed in cartilage and their cen- 




^ 




Fig. 34. — Epiphyseal lines of part of pelvis and upper end of femur. 



tres form in a similar manner to those of the first metacarpal. This 
embryologically is a phalanx having a diaphyseal centre,, with its epiphy- 
seal centre in the proximal end. The proximal phalanges show basal cen- 
tres of ossification at about 3 years, then the middle row, and finally the 
distal ones. The shafts and bases consolidate at about nineteen years. 



EPIPHYSEAL SEPARATIONS 



53 



The innominate bone (Figs. 34 and 35) is preformed in cartilage, 
there being three main centres of ossification, one for the ilium, one for 
the ischium, and one for the pubes; the centres appearing at the third, 
fourth and fifth months of fetal life, respectively. At birth a large part 
of the innominate bone is cartilaginous and remains so for some time. 
The three portions join by the ossification of the Y-shaped cartilage, 




Fig. 35. — Epiphyseal line of crest of ilium. 



where they meet in the acetabulum, about the sixteenth to the twentieth 
year. There are, in addition, secondary centres of ossification as follows : 
one each for the crest of the ilium, the tuberosity of the ischium, the 
spine of the ischium, the symphysis pubis, the anterior inferior spine of 
the ilium, the spine of the pubes, and two for the acetabulum. These 
epiphyses unite with the main portion of the bone about the twenty- 
fifth vear. 



5-4 TEEATISE OX FBACTUEES 

Femur (Figs. 34 and 36). — This bone develops from a diaphyseal 
centre and two primary epiphyseal centres. The diaphyseal centre 
appears about the seventh week of embryonic life and the lower epiphyseal 
centre is generally visible at birth ; the centre for the head appears about 
the end of the first year, that for the great trochanter about the fourth year, 
and that for the lesser trochanter about the fourteenth year. The 
epiphyses unite with the shaft in the following order and time : lesser 
trochanter, seventeenth year; great trochanter, eighteenth year; head, 
nineteenth year ; condyles, twentieth to twenty-first year. The neck is an 
outgrowth from the shaft. 

Patella (Fig. 36). — The patella is formed from a single centre of 



FlG. 36. — Epiphyseal lines of lower end of femur, of patella, and ends of tibia and fibula. 

ossification, which appears about the fourth year, and ossification is 
complete about the fifteenth year. 

Tibia (Figs. 36 and 37). — The centre for the diaphysis appears about 
the seventh week of fetal life; the centre for the upper epiphysis which 
includes the tubercle ossifies about the time of birth, and the centre of the 
lower epiphysis ossifies about the beginning of the second year. The 
lower epiphysis unites with the shaft about the eighteenth year and the 
upper epiphysis about the twenty-second year. 

Fibula (Figs. 36 and 37)- — The centre for the diaphysis appears about 
the eighth week of embryonic life; the centre for the lower epiphysis 
appears about the second and that for the upper epiphysis about the third 
or fourth year. The lower epiphysis unites with the shaft about the 
twentieth year and the upper one from the twenty-second to the twenty- 
fourth year. 

Tarsal bones (Fig. 37). — The centre for the calcaneum appears 
about the sixth month and that for the astragalus in about the seventh 



EPIPHYSEAL SEPARATIONS 



55 



month of embryonal life; the centre for the cuboid appears at birth; the 
external cuneiform ossifies about the first year, the internal cuneiform 
the second year and the middle cuneiform and the scaphoid from the 
fourth to the fifth year. The calcaneum is the only tarsal having an 
epiphyseal centre of ossification which appears about the tenth year and 
unites with the remaining part of the bone at about the fifteenth or 
the sixteenth year. 

Metatarsal Bones (Fig. 38). — The centres of the diaphyses appear 




Fig. 37.— Epiphyseal lines of lower end of tibia and fibula, and of ealeaneum. 



about the eighth to ninth week of fetal life and the epiphyseal centres 
in the third to the fourth year and unite with the diaphyses about puberty. 
The ossification is similar to that which takes place in the metacar- 
pal bones. 

Phalangeal Bones (Fig. 38). — Here the process of ossification is 
similar to that seen in the phalanges of the hand. The centres of the 
diaphyses appear in about the third month of fetal life, the epiphyseal 
centres in about the fourth year, and union of the diaphyses and epiphyses 
takes place about the time of puberty. 



56 TEEATISE OX FRACTUKES 

Etiology of Epiphyseal Separation. — Epiphyseal separations may be 
due to violence, direct or indirect, or to muscular action. 

Direct Violence. — This is a frequent cause of epiphyseal separa- 
tions which are produced by force applied close to the epiphyseal line. 
Examples are : fall from a moderate height and striking the shoulder, 
catching an extremity in a revolving wheel or having a wheel pass over 
it, and having the part struck by a heavy object. 

Indirect Violence. — Epiphyseal separations are produced by in- 
direct violence as in falls upon the hand, producing separations at the 
epiphyses in the young where fractures would be produced at the same 
site in the adult. Examples of separations are : those at the wrist simu- 
lating Colles's fracture, separations at the elbow by falling upon the hand 




Fig. 38. — Epiphyseal lines of metatarsal and phalangeal bones of foot. 

or by hyper-flexion or -extension, or catching the limb in a revolv- 
ing wheel. 

Muscular Action. — This is a very rare etiologic factor in epiphy- 
seal separations. It is occasionally seen in severe muscular action, by 
which an epiphysis may be displaced owing to the attachments of strong 
muscles or ligaments. The same amount of strain in an adult would 
probably produce a sprain fracture or the separation of an apophysis. 
An example of this is separation of the tip on the internal epicondyle of 
the humerus. The mechanism of most epiphyseal separations, or diastases, 
is the same as that which produces fractures near joints in adults. 

Occurrence of Epiphyseal Separations. — Ossification of all the 
epiphyseal cartilages has usually occurred before the twenty-fifth year, 
hence a diastasis can rarely happen at a later period of life. Poland 
has shown that epiphyseal separations are rare before the age of four 
years, excepting, of course, those produced in obstetric delivery. They 
are most frequently found between eleven or twelve and sixteen years. 

Dependent upon the age of the patient, there may be several forms 



EPIPHYSEAL SEPAEATIONS 57 

of separation of the epiphyses. In early childhood the separation does 
not involve the diaphysis to any appreciable extent. After the age of 
eight or nine, nearly all epiphyseal separations are accompanied by a 
fracture of the diaphysis, which may be vertical or oblique, or consist 
of only a very small part of the cortex of the diaphysis. With the 
increase of age occurs a greater tendency for marked stripping off of 
the periosteum. In early childhood this is not marked, but in later 
childhood it may extend four to five inches along the shaft of the bone. 
The extent of this stripping is dependent upon the degree of displace- 
ment and the particular epiphysis involved. It is greatest in separations 
of the lower epiphysis of the femur and the upper epiphysis of 
the humerus. 

A point to be borne in mind in separations of the epiphysis is that 
fracture of the epiphysis itself may be associated with the diastasis. 
This is most commonly met in separations of the lower epiphysis of 
the radius and in those of the metacarpals and phalanges. 

Separation of the epiphysis may involve single epiphyseal centres, or 
combined epiphyseal centres ; the latter condition is seen when childhood 
is advanced and the several centres forming an epiphysis have fused. 

Epiphyseal separations may be complete or incomplete. Complete 
epiphyseal separation exists when the epiphysis is entirely torn from its 
attachment to the shaft. Complete separations are produced by great 
violence, or when obliquity of the line of the epiphyseal cartilage permits 
disunion by moderate violence. Incomplete separations are the most 
common form. They are frequently mistaken for sprains, and even with 
radiographic examination may be overlooked. In most cases, however, 
a careful examination of the radiographic plate will disclose a little irregu- 
larity of the surface lines of the bone or a slight fracture of the epiphyseal 
end of the diaphysis. At times it is impossible to distinguish clinically 
between epiphyseal separation and a fracture of the diaphysis. A radio- 
graphic examination should be made in all suspected cases. 

Symptoms. — Age. — Injuries about joints in childhood and adolescence 
should immediately bring to mind the possibility of epiphyseal separation. 
The presence of marked swelling near a joint should suggest such 
an.accident. 

Mobility. — This is dependent upon whether the separation is com- 
plete, incomplete or impacted. When the separation is not impacted 
there is usually slight mobility in incomplete separations and marked 
mobility of the epiphysis in complete separations. The mobility is de- 
pendent upon the extent of laceration of the ligaments and periosteum. 

Deformity. — This may consist of swelling only about the joint. 
There may be no deformity in incomplete and in reduced separations. 
In complete separations the metaphyseal end of the epiphysis may be 
felt as an irregular, smooth prominence; and the size and shape of the 
involved epiphysis may be outlined. It is well to remember, however. 



58 TREATISE OX FRACTURES 

that in many cases there may be an attached fragment of the diaphysis, 
which will alter the normal shape of the epiphyseal fragment. The axis 
of the limb may be displaced, as in fracture or dislocation. The proximal 
end of the shaft may project so much as to be mistaken for the head of 
an unbroken but dislocated bone. 

Crepitus. — This differs from the crepitus found in true fractures. 
When it can be elicited, it is soft in character, and may be produced only 
by rather vigorous manipulation. In impacted diastasis it is absent; in 
separations in which there is a fairly large sized piece of the diaphysis 
attached, it may be more bony in character. 

Pain. — This is not as great as in fractures. There is, however, 
generally localized tenderness on pressure over the epiphyseal line; this 
symptom, combined with localized swelling, is of great diagnostic value 
in recognizing epiphyseal separations. 

Ecchymosis is not as marked as in fractures. This is probably due 
to the fact that the vascular system involved consists of terminal vessels. 
When present it becomes evident about the fourth to fifth day. 

Radiograph Examinations, — These are of especial value and should 
always be made in suspected cases. Skiagraphs should be made in several 
planes, as it may be that positive diagnosis is possible only by comparison 
of the outline of the affected bone with that of the normal side. The 
surgeon should particularly familiarize himself with the normal X-ray 
appearances of the epiphyses at all ages, that correct interpretation of 
these radiographic plates may be made. Examination of the plates by 
transmitted light is much more satisfactory than inspection of prints. 
More care is required than in fractures. Very often the only abnormality 
to be seen will be a slight difference in outline of, or loss in normal con- 
tinuity of the compact shell of epiphysis and diaphysis. In other cases 
one may discover a fissure or a partial fracture of the metaphyseal end 
of the diaphysis, with displacement of the fragment along with the 
epiphysis ; in still other cases there may be noted a stripping off of perios- 
teum. Radiographic pictures of the normal corresponding part should 
be taken for comparison with the injured side. 

Diagnosis. — This is made from a consideration of the patient's age, 
the nature and position of the injury, the site of tenderness and swelling, 
the characteristic displacement if any be present, the absence of true 
bony crepitus, the presence of mobility in the region of the epiphyseal 
line, and, lastly, by radiographic examination. The last is of utmost 
importance in the recognition of these lesions. The similarity of the 
deformity to that of a luxation of the joint makes a radiographic study 
very desirable. This is particularly the case in injuries at the shoulder. 

Complications of Epiphyseal Separations. — These are injuries to 
blood-vessels, and lesions from nerves being caught between the diaphysis 
and the epiphysis, fracture of the diaphysis, rotation and displacement of 



EPIPHYSEAL SEPARATIONS 



59 



the epiphysis, necessitating operative exposure for proper replacement, 
and the occasional occurrence of an open epiphyseal separation. 

Sequelae of Epiphyseal Separations. — Perfect reduction of epiphyseal 
separations should give perfect anatomical and functional results. It is 
surprising how rarely there is any interference with the subsequent 
growth of the bone after such injuries. While there are cases of subse- 
quent interference with the growth of the bone (Fig. 39), this sequel 




Fig. 39- 



-Shows interference with subsequent' growth of the fourth metacarpal 
following a previous epiphyseal separation. 



seems to be rare in comparison with the great number of epiphyseal 
separations observed in childhood. 

Treatment. — In all cases of complete or incomplete separation of the 
epiphysis, attempts at reduction should be made. An anaesthetic will be 
required in many instances. Very often stripped off periosteum or rota- 
tion of the epiphysis will prevent accurate anatomical reduction. Then 
deformity is found to be persistent and probably interference with growth 
will occur. In these cases, if proper reduction cannot be accomplished, 
the site of the epiphyseal separation should be exposed under the most 
thorough aseptic precautions and reduction secured. The reposition 



60 TREATISE OX FRACTURES 

may be maintained by a few absorbable sutures, uniting torn ligaments, 
periosteum, or surrounding muscles. \\ nile some authorities advise direct 
suture of the epiphysis to the diaphysis, we are not in accord with this 
teaching as a routine, and believe that as good results can be accomplished 
by the means outlined above without running the chance of possibly 
interfering with subsequent growth of the bone. In all cases after reduc- 
tion, the form of external support should be similar to that used for 
fracture of the diaphysis near the end of the bone involved. Open epiphy- 
seal separations should be treated like open fractures near joints. 



CHAPTER III 

TREATMENT OF FRACTURES 

General Considerations. — The ideal objective in the treatment of all 
fractures is an anatomical and functional cure — to restore the fragments 
to a normal position so far as it is possible to do so, and to give the 
patient the best functional result obtainable. The surgeon's object should 
be to secure prompt union with as little deformity as possible. Unfortu- 
nately, at times, a certain amount of deformity is unavoidable, on account 
of the situation and the nature of the fracture or of the patient's general 
condition. Usually bony union of the fragments is not difficult to obtain. 
Those injuries in which there is gross displacement of fragments are read- 
ily recognized ; and their reduction and retention in anatomical apposition 
ordinarily may be readily attained. In a fair number of instances, how- 
ever, union is obtained with deformity, and interference with subsequent 
function results. The degree of impairment of function and the loss of 
earning capacity of the patient vary, not only with the variety of fracture 
but also with the patient's occupation. Impairment of function may be 
very serious in a patient whose occupation depends upon the perfect use 
of the part, while the same condition will have little influence in the 
earning capacity of another. Fractures about joints may seriously impair 
the earning capacity of patients whose livelihood depends upon the full 
use of their extremities. Impairment of function after fractures of 
the lower end of the radius may seriously reduce the earning capacity 
of musicians and artists. Bad results after fractures of the femur in 
the neck or above the knee, and especially after fracture of the tibia near 
the ankle-joint seriously impair the earning capacity of individuals whose 
occupation requires marching or prolonged standing. Coxa vara, knock- 
knee, flatfoot, chronic arthritis, are such conditions resulting in 
impaired function. 

Not only should the radiogram be one of the guides to diagnosis, 
when practicable, but it may also be an aid in successful treatment and of 
value in estimating ultimate results. Perfect reduction and maintenance of 
proper position of fragments are at times difficult, and mere routine 
methods of non-operative treatment may be found inadequate. A 
careful study of each fracture by the attending surgeon, and proper 
supervision of treatment often, however, will result in better functional 
results than was anticipated. The tendency toward operative treatment 
of fractures at present much in vogue is an indication of the poor results 
obtained by ordinary means in inexperienced or careless hands. If the 
same degree of attention was given to fractures as is given to abdominal 

61 



62 TEEATISE OX FEACTUKES 

surgery, there would be better results obtained; and many obsolete 
methods used in the treatment of fractures, even in large hospitals, 
would be replaced by forms of treatment based upon an intelligent study 
of each case. It is not that there is needed many radical changes in 
treatment to-day. The fault lies in hospital chiefs delegating to assistants 
and to house officers the complete care of fracture patients. If sur- 
geons wish to obtain good results, it behooves them to give fractures the 
very best attention. The use of the X-ray has shown their shortcomings, 
and it is only a question of time until the public will demand more efficient 
treatment, better anatomical and functional results, and less incapacitation 
from work. 

The treatment of fractures may be considered under the following 
heads : 

1. Temporary immobilization of the fragments, transportation of 
the patient. 

2. Reduction of the fragments. 

3. Retention of the fragments: ( 1) without traction; (2) with trac- 
tion (temporary, permanent) ; (3) with massage and passive motions. 

4. Attention to the soft parts. 

5. Functional treatment. 

6. After-treatment. 

Temporary Immobilization of the Fragments, Transportation 
of the Patient. — In cases of suspected fracture it is not always neces- 
sary or wise to make an immediate diagnosis. One's efforts should be 
confined to temporary immobilization of the part, so that the patient may 
be transported to the hospital, home, or physician's office for treatment. 
There are many simple first-aid dressings which may be applied by the 
ambulance surgeon or by laymen. Fractures of the clavicle and humerus 
may be temporarily immobilized by the use of a suitable sling and fixation 
to the side; fractures of bones of the forearm and hand by an anterior 
splint of wood with suitable padding and bandages and sling; fractures 
of the jaw by an occipitomental figure-of-8 (Barton) bandage; and 
fractures of the ribs, sternum, or costal cartilages by a circular bandage 
of the chest, or by a swathe of muslin or of adhesive plaster. Fractures 
of the pelvis should be temporarily immobilized by a tightly applied 
swathe of muslin or adhesive plaster around the hips ; those of the femur 
should be supported by a posterior splint from the buttocks to the heel 
and by an external splint from the axilla to the sole. If splints are not 
obtainable, a temporary splint may be made for the thigh bone from 
broom handles or branches of trees and a blanket; or the patient may be 
transported on a board. Fractures of the lower part of the femur and of 
the bones of the leg may be temporarily supported in a -pillow and side 
splints of wood. Patients with severe fractures and with fractures of 
the upper extremities, when the shock is great, should always be carried. 
Cases of fracture of the vertebra and pelvis should be very carefully trans- 



TREATMENT OF FKACTUBES 63 

ported, in order not to increase the injury of the spinal cord, or of the 
internal viscera. 

Special beds are convenient in the treatment of fractures requiring 
the recumbent position. The bed should be a narrow one and preferably 
high, so that the attendant may readily lift the patient and easily reach 
each part of his body. A firm hair mattress laid upon slats is the best. 
Any good mattress, without springs, which does not permit sagging 
may be used. The usual hospital bed may be converted into a fracture 
bed bv placing slats, underneath the mattress, resting on the sides of the 
frame. A special opening in the mattress for using a bedpan is not 
necessary, if the bedpan and urinal are carefully and intelligently placed. 
It is important in fractures of the femur that the bedpan be not a high 
douche pan, but a receptacle that may be slipped under the hips without 
raising the buttocks much from the surface of the bed. If the patient's 
foot is fastened to traction apparatus, this is especially important. A 
large deep soup plate makes an excellent bedpan. For cases of fracture 
of the vertebrae or pelvis a special air mattress is advisable so that pres- 
sure sores may be avoided. 

The sheet under the patient should be kept perfectly smooth and 
should have over it a rubber sheet and a narrow draw sheet; the one for 
protection to the full size sheet and mattress, the other to permit frequent 
changing without greatly disturbing the patient. During a long con- 
finement to bed, special attention should be paid to the back of the 
shoulders, the sacral regions and the heels, which are subject to pressure. 
These parts should be washed twice daily with alcohol containing a small 
amount of alum and dusted plentifully with a smooth powder, such as 
stearate of zinc. The greatest possible care should be taken to prevent 
" bed-sores " in these regions. A rope, hanging from the ceiling directly 
over the patient's chest, with 12 inches of broom handle at the end, will 
often permit a fracture patient to lift his trunk from the bed with safety. 

Reduction of the Fragments. — After the patient has been trans- 
ported to his home, to the hospital, or to the physician's office, a thorough 
examination of the injured part should be made. Great care should be 
observed in the examination of all suspected fractures. The clothing 
should be removed from both the injured and the corresponding uninjured 
region, in order to give opportunity for comparison of the anatomical 
landmarks. It is not necessary to cause pain in the examination of frac- 
tures. The surgeon's diagnosis should be made by inspection, by palpa- 
tion, measurement, and radiography. If the clothing cannot be readily 
taken off, it may be cut and then removed. Before reduction is attempted 
all apparatus for retention should be at hand and assistants present to 
give help. Many fractures of the small bones may be reduced without 
anaesthesia. General anaesthesia, as a rule, should be used in the reduction 
of fractures of the long bones, in all fractures where satisfactory reduc- 
tion cannot be accomplished without causing needless pain, when muscu- 



64 TREATISE OX FRACTURES 

lar spasm must be overcome, when fractures are complicated with other 
conditions, and when the radiograph shows failure of anatomical apposi- 
tion of the fragments following previous attempts at reduction. 

Post-mortem examination of a recent case of fracture may show quite 
an extensive disorganization of muscles, infiltration of the soft parts, and 
extravasated blood. These conditions accompanying the injury are to a 
great extent due to movements of the sharp fragments of bone and are 
not so much the result of the original traumatism itself as to failure of 
temporary splinting of the part during transportation, to improper hand- 
ling on the part of the patient's friends, or to temporary examination by 
physicians. To prevent such injury the parts should be protected by an 
improvised splint and proper precautions during transportation, to 
insure immobilization. 

The most important object in the treatment of fractures is proper 
reduction. Without complete reduction, proper anatomical apposition 
and correct alignment of the fragments are impossible; and the subsequent 
treatment may be valueless so far as perfect contour and good functional 
results are concerned. Hence a large proportion of fractures should be 
reduced under general anaesthesia. Ether or perhaps nitrous oxide gas 
with oxygen is the preferable agent. Other general anaesthetics are, 
however, used. By anaesthesia the surgeon is able to overcome muscular 
spasm, thoroughly to avoid pain, to calm the apprehension of the patient, 
and to separate impaction of fragments when this is necessary for com- 
plete reduction. Moreover, interposition of soft parts may be more 
readily recognized and removed by manipulation, and dislocations accom- 
panying fractures reduced. Above all else, perfect replacement of the 
fragments is much more likely to be obtained under general anaesthesia ; 
without anaesthesia only partial reduction may be unwittingly accepted. 
Lerda and Quenu have used cocaine or novocaine to diminish muscular 
spasm and pain. They inject a solution of the drug into the muscles 
and tendons about the fracture and if possible about the regional nerve. 
They also force it into a joint capsule, and into tendons and ligaments 
above the joint. This method to overcome muscular spasm and pain 
may be useful for patients in whom old age, defective cardiac or renal 
function, shock, etc., contra-indicate general anaesthesia. 

Time of Reduction. — As a general rule, reduction of the fragments 
should be performed as soon as shock has been overcome and proper 
facilities are at hand for retention of the fragments. In some cases 
immediate reduction is imperative and should be performed at once. 
These are injuries in which the fragments press upon or are lacerating 
important vessels or nerves, or in which sharp fragments are about to 
perforate the skin or penetrate important vessels, nerves, or viscera. 

Obstacles to Reduction. — Reduction may be prevented by interposi- 
tion of soft parts between fragments, rotation of small pieces of bone, 
piercing of muscles, tendons, and fasciae by the sharp ends of fragments, 



TREATMENT OF FRACTURES 65 

the presence of an accompanying dislocation, impaction of fragments, 
extreme subfascial swelling, and muscular spasm. Associated injuries or 
complicating conditions, such as profound shock, hemorrhage, or ap- 
proaching death may render immediate attempts at replacement unwise. 
When it is impracticable for any reason to immediately reduce the frag- 
ments, the reconstruction, as a rule, should not be delayed more than about 
a week. In the meantime efficient immobilization of the fragments, com- 
bined with extension if necessary, should be maintained. 

The actual reduction of a fracture varies with the situation and 
variety of the lesion. No one method is applicable to all fractures. In 
fractures of the long bones reduction, as a rule, is accomplished by trac- 
tion, counter-traction, manipulation, and lateral moulding. The surgeon 
estimates by palpation, measurement, and comparison with the opposite 
side, the extent of displacement needing correction, and similarly deter- 
mines the degree of reduction, alignment, and anatomical apposition which 
has been accomplished. As a rule, he attempts to reduce the fragments 
by flexion of joints to overcome muscular spasm and then tries to bring 
the lower fragment or fragments into, proper relation with the upper by 
rotation, abduction, adduction, flexion and extension, combined with trac- 
tion. Fractures, in which it is recognized that the proximal fragment 
assumes a certain position from the pull of attached muscles, are reduced 
by bringing the distal fragment into appropriate position. Impacted 
fractures may be reducible only by considerable force, which must be 
applied so as to break up the impaction before the readjustment is possible. 
Powerful bending may be required to unlock the impaction. Fractures 
accompanied by overlapping or by lateral displacement, in which the line 
of fracture is serrated and transverse, may generally be reduced by trac- 
tion alone. Often direct pressure and lateral traction combined with axial 
traction may be necessary to produce reduction of fragments. Rotary 
displacement may be corrected by proper rotation of the lower fragment. 
Subperiosteal, green-stick and impacted fractures are often corrected by 
forced flexion and extension. Fractures associated with dislocation may 
often be reduced by first reducing the dislocation and then the fracture. 

When, for any reason, reduction cannot be accomplished and there 
is no contra-indication to open operation, perfect reduction and coapta- 
tion of the fracture surfaces should be performed by exposure of the 
line of break, under thorough aseptic precautions, by men trained to do 
this class of surgery. 

Retention of Fragments. — The important feature in the treatment 
of fractures, after proper reduction, is the retention of the fragments 
in proper alignment and the prevention of subsequent deformity. To 
obtain perfect anatomical, as well as perfect functional results, should be 
the aim; the accomplishment of the latter, as a rule, will follow the obtain- 
ing of the former. The statistics of the British and the American Com- 
mittees on Fractures show the dependence of good functional results upon 
5 



66 TREATISE OX FRACTURES 

perfect anatomical results; and that a large percentage of poor functional 
results follow poor anatomical results. This means, in the majority of 
cases, faulty reduction, inadequate retention, or lack of proper observation 
and care on the part of the surgeon in charge. It should, however, be 
borne in mind that good physiologic repair should be striven for in 
muscles and tendons as well as in the bone itself. After reduction has 
been accomplished, the form of retentive treatment will depend upon the 
site and variety of fractures. The retention of the fragments and the 
prevention of subsequent deformity may be accomplished by several 
means. These methods may be divided into temporary dressings, contin- 
uous or permanent dressings, fixation dressings, traction dressings, com- 
bined fixation with traction, and ambulatory dressings. 

Temporary dressings are used generally to prevent suffering and 
to protect the soft parts from injury by sharp fragments of bone during 
transportation of the patient to the place of treatment. They are used 
also until the maximum swelling has occurred, or for the retention of 
fragments after reduction until such a time as a continuous or permanent 
dressing may be safely applied. In some fractures a form of fixation 
may be used as a permanent as well as a temporary dressing. These cases 
are mainly those in which traction is not required. Temporary dressings 
are seldom efficient enough to prevent recurrence of deformity. 

It must be understood that by permanent dressing is not meant a 
dressing by which the fracture is excluded for several weeks or days from 
the observation of the surgeon. The shutting up of broken bones in 
fracture apparatus for long periods is to be deprecated. It is a fruitful 
cause of undetected deformity, atrophy of muscles, rigidity, and anky- 
losis. After reduction has been obtained, there is generally no need of 
local applications like lead water and laudanum and similar remedies. 
Their efficacy is questionable and they often produce maceration of 
already devitalized skin and subcutaneous tissues. Immobility and the 
prevention of muscular spasm are therapeutic agents of far greater value 
than local applications. The use of the ice-bag may be of some benefit by 
lessening the amount of exudate. Its use, however, should be carefully 
watched, as it may cause areas of necrosis. 

After reduction has been satisfactorily accomplished there are a few 
cases in which retentive apparatus is not needed. These cases are, how- 
ever, rare. A greater safety against displacement of the fragments 
and the confidence of the patient will usually be better obtained by the 
use of some form of retention. The best fracture dressings are those 
which correct the tendency toward displacement in the individual case, 
preserve anatomical alignment, and prevent overriding. The special 
tendency toward displacement varies in each case with the line and position 
of fractures; this should be recognized before the dressing is applied. 

Fracture dressings may be grouped under the following heads : 

(i) Those which secure fixation of the fragments by virtue of their 



TREATMENT OF FRACTURES 67 

inflexibility, and prevent angular or lateral displacement; and in which 
no traction is employed. 

(2) Those in which strong traction with countertraction is the prin- 
cipal feature upon which anatomical coaptation of fragments and their 
proper alignment depend. 

(3) Those in which moderate traction and indirect fixation are the 
means of retaining efficient reduction of the fragments. 

Very often there may be a combination of several features in the 
treatment used. The simplest methods and apparatus may give best re- 
sults. The various articles used in fracture dressings are rigid splints 
of wood, fibre, aluminum, wire, felt, or pasteboard, applied with bandages 
or adhesive plaster after appropriate padding with cotton or sheet wad- 
ding; contour splints of gauze stiffened with plaster-of-Paris, silicate of 
soda, starch, or celloidin; fracture boards; and various apparatus for 
traction, countertraction, permitting mobility of joints, and elastic pressure 
constructed for orthopaedic purposes. 

The following general rules apply in the application of all forms 
of dressings : 

( 1 ) Do not apply tight bandages next the skin of the limb. 

(2) Do not apply any dressing that is too constricting in character 
or which does not allow for swelling to take place. 

(3) Have all splints well padded and do not depend on pads to reduce 
a deformity. Contour splints moulded to surface are preferable. 

(4) Examine every fresh fracture daily after reduction for about a 
week, and correct immediately any deformity that may occur. Then 
examinations may be made every other day for a week or so. Subse- 
quently, twice a week will probably be often enough to inspect the uncov- 
ered region of injury. 

(5) Use general anaesthesia a second time for reduction, if the X-ray 
plates taken at right angle do not show good anatomical apposition of 
the fragments. 

(6) It is well to have an X-ray photograph made in two planes at a 
right angle to each other after reduction. The X-ray tube must be placed 
vertically over the fracture and at the same distance from the skin at 
every radiographic exposure. The same angle of incidence of the rays 
must be obtained, if errors in the estimation of degrees of deformity are 
to be avoided. 

(7) In fractures of the long bones, it is sometimes necessary to im- 
mobilize the joints above and below the seat of fracture; but do not con- 
tinue this long. 

(8) Splints which are not moulded to the part should be more Care- 
fully and more thickly padded with sheet wadding than moulded ones. 
The latter may fit so well as practically to need no padding. 

(9) Many surgeons fix splints to the part directly with adhesive 
plaster, and do not depend upon bandages alone for keeping splints 



68 TREATISE OX FRACTURES 

in position. Remember that adhesive plaster may cause danger- 
ous constriction. 

(10) In dressing fractures of the extremities, usually keep the fingers 
or toes uncovered, so that lividity, coolness, or cedema, due to improper 
constriction, may be noticed at once and proper measures taken to pre- 
vent harm. Do not fail to remember that Volkmann's ischaemic con- 
tracture and paralysis may be induced by a less degree of pressure than 
that which causes lividity and cedema. Complaint of pain and tightness 
by the patient usually means that the doctor should remove and reapplv 
the fracture apparatus. 

(n) Before applying or reapplying a fracture dressing, the skin 
should be washed with soap and water and then gently rubbed. Alcohol 
diluted with water is an acceptable substitute for soap and water. If the 
skin is hairy it should be shaved before the fracture is dressed. 

(12) Before the retentive apparatus selected for treatment has been 
applied, gentle frictions and light massage, with passive mobility of joints, 
should be employed. This should be done at every dressing. After the 
first week or so the patient should be encouraged to move the joints a 
little at each dressing. 

Splints. — The most common retentive dressings are made of wooden 
splints, which are appropriate strips of wood padded with wool, cotton, 
sheet wadding or other soft and elastic material. One or several ma}- be 
required to give rigid support to the broken bone. For small splints 
hasswood, three-sixteenths of an inch thick, is very satisfactory. For 
large splints any kind of light wood may be used. Felt, pasteboard, or 
modelling compositions, which become pliable when welted or warmed 
may be used instead of wood for splints. These need less padding under 
them, because they may be moulded to -the surface of the limb when soft- 
ened and then applied when they become hard and rigid. 

Wooden splints differ in shape and size in accordance with the func- 
tion which they are to perform. They may be angular when applied 
to a limb so as to control the action of a joint, or straight and narrow 
when used for coaptation around a limb at the seat of fracture. Several 
narrow splints placed parallel to each other may be wrapped between 
layers of adhesive plaster so as to surround the limb for maintaining coap- 
tation of fragments, while permanent traction or other apparatus may 
be used to prevent overlapping. The illustrations show several varieties 
of splints. For temporary dressings pillows or folded sheets or anything 
that gives rigidity with softness may be used. 

Special splints of wood have been devised for use in fractures of 
particular bones, as internal and anterior angular and the Stromeyer 
splints for the upper limb, the Agnew patella splint, the fracture box for 
fractures of the bones of the leg, the double inclined plane, for broken 
shaft of the femur, the Petit elevated fracture box, the Mitteldorf triangle 
for the humerus, the Volkmann sliding splint for the lower extremity, 



TREATMENT OF FRACTURES 



69 



and the Liston thigh splint. In addition to these there are many other 
ready-made splints of wood named after the surgeons who have devised 
them to meet the indications in various fractures. There are also many 
forms of carved or moulded wooden splints made in different sizes to fit 
various parts and to be used at all ages. Nearly all wooden splints are 
inferior to plastic splints made of gauze dipped in plaster-of-Paris mixture 
and moulded to the part before the gypsum paste has set. These " con- 
tour " splints fit and need little padding; wooden splints are inferior in 
this particular. 

Metal Splints. — There is a great variety of metal splints in use. They 
are made of wire or wire gauze, aluminum, perforated zinc or tin, or 




Fig. 40. — Method of making moulded gypsum contour splints. 



other metals. The most serviceable metal splints are those made in sizes 
suitable for adults or children, and which are sufficiently flexible to allow 
the surgeon to modify their contour to fit the patient's requirements. 
Sir Robert Jones, of Liverpool, has advocated for years strips of close 
mesh wire gauze, slightly concave transversely. These are used instead of 
wooden splints, because they are readily twisted or even bent into such 
shapes as are needed to steady the fragments of bone. The Hodgen heavy 
wire splint for the thigh, the Thomas traction splint for the thigh or leg 
are valuable. 

Moulded Splints. — These are made of leather, poroplastic felt, cellu- 
loid paper, modelling materials, and substances suitable for moulding 



TEEATISE OX FKACTCRES 

Fig. 41a. Fig. 41b. 




Fig. 41c, 



Fig. 41a. — Moulded gypsum shoulder-cap. 

Figs. 416, 41c, and 41^. — Method of using gypsum bandages in treating fracture of the clavicle. 

Fig. 41b. — Pad over prominent outer end of inner fragment, and separation of skin surfaces by layer 

of sheet-wadding. 
Fig. 41c. — Modified Velpeau bandage of muslin. 
Fig. 4 id. — Gypsum bandage applied over muslin bandage, giving firm fixation. 



TREATMENT OF FRACTURES 

Fig. 42a. Fig. 426. 



71 




Fig. 42c 



Fig. 42d. 



Fig. 42a. — Gypsum case applied over flannel bandage for fracture of shafts of both bones of forearm. 

Fig. 42b. — Moulded gypsum splint for fracture of shaft of radius or of ulna. 

Fig. 42c. — Anterior and posterior gypsum splints for fracture of lower end of radius. 

Fig. 42d. — Method of applying gypsum splints by means of a muslin bandage. 



72 



TREATISE OX FEACTUEES 



when softened by heat or moisture. As a general rule they are made in 
five or six sizes, suitable for adults and children. 

Plaster-of -Paris. — The best and a very cheap means of dressing frac- 
tures is by splints made from plastic material for each patient by the 
surgeon himself. The use of plaster-of -Paris (gypsum) in the construc- 
tion of splints or encasements for fractures is now very general. The 
gypsum powder should be fresh, dry, fine, and contain no par- 
ticles of grit. It is made into a pasty mixture with water and used to 
stiffen, by setting, porous materials, such as crinoline or cheese-cloth. 
Accurately fitting splints or encasements are thus moulded to the surface 



Fig. 43a. 



Fig. 43b. 




Fig. 43a. — Moulded gypsum splint for fracture of first metacarpal. 
Fig. 43b. — Circular gypsum case for fracture of carpal bones or of first metacarpal. 



of the patient. The material used for the foundation of the dressing may 
be cut into long strips, and the dry plaster rubbed into its meshes. These 
gypsum bandages are then dipped into water when required, applied to 
the limb longitudinally or circularly, and given time to harden. The 
encasement when dry and firm is split so as to be easy of removal when 
the surgeon wishes to examine the fracture. The moulded " contour " 
splints or the encasements fit the surface of the body and can be readily 
removed and reapplied. The circular encasements of gypsum are often 
erroneously called " casts." They are of course " moulds " of the limb 
and not " casts." 

The best variety of plaster-of-Paris is dental plaster. The best 
supports for the plaster are crinoline which has been thoroughly washed, 



TREATMENT OF FRACTURES 73 

rinsed, and dried, cheese-cloth, mosquito netting, or gauze of fairly large 
mesh. Plaster bandages may be purchased ready for use or may be 
made by the surgeon or his assistants. A little experience will show the 
proper amount of Paris plaster to be rubbed into each bandage, and also 
how loosely the bandage should be rolled. The plaster should be thor- 
oughly rubbed into the meshes of the cloth, and, after being made, the 
bandages should be separately encased in wax paper and stored in an air- 
tight and moisture-proof can. Bandages should be made of various 
widths, the most useful being two, three, and four inches. In making large 
moulded plaster splints the size and shape of the part to> be: covered may 
be first ascertained by making a model in paper. About ten to fifteen 
layers of netting should then be cut a little larger than the model and 
thoroughly impregnated with the powdered gypsum. These layers are 
laid one upon another, wetted and applied to the part. Another way is to 
lay the paper model on the table, cover it with twelve to fifteen layers 
of a wet plaster bandage unrolled back and forth, and while it is still 
wet apply it to the part (Figs, 40-46) . A gypsum, paste moderately thick- 
ened may, before it sets, be poured upon superposed layers of dry surgical 
gauze. This is the more satisfactory method when large irregular splints 
are to be made, as, for example, in fractures of the pelvic bones. 

In using plaster-of-Paris bandages the part to which the encasing 
dressing is to be applied should be first protected by a layer of flannel 
bandage or by sheet wadding. Then a one-inch wide strip of lead, 
greased and wrapped in paraffin paper, may be placed lengthwise of the 
limb over this layer. Above the metal the plaster bandages are applied. 
The dried dressing may be readily split with a knife over the lead 
without cutting the patient's skin or spoiling the knife's edge. Lead tape 
is flexible and convenient, but is not necessary. If it is wrapped in 
paraffin paper before the bandages are applied, it can be readily with- 
drawn after the dressing is split. Encasing gypsum dressings applied to 
the extremities should be cut down on one or both sides immediately after 
application. On no account should a circular plaster-of-Paris bandage be 
applied as a primary splint, unless all inflammatory swelling has occurred 
and is subsiding. xA good rule to adopt is never to apply a circular gypsum 
dressing until after the fifth day unless it is cut down both sides imme- 
diately and all possible constriction is removed. Tight encasements may 
give rise to Volkmann's contracture of muscles by pressure on vessels 
and nerves. This so-called ischemic myositis should be borne in mind 
when the patient complains of pain from a tight " case." Less pressure 
than that which causes gangrene of toes or fingers may cause the onset of 
this crippling damage. Beware of it ! 

In using the dry plaster-of-Paris bandages there should be placed 
five or six of them in a pail of lukewarm water, which should be deep 
enough to cover them completely. It is not necessary to place salt or 
alum in the water to promote hardening of the plaster. After all air 



74 



TREATISE OX FRACTURES 



bubbles have escaped, the bandages should be gently squeezed from both 
ends to express the excess of water and applied without constriction. 
Each succeeding layer should be carefully rubbed against the one under- 



Fig. 44a. 




Fig. 44a. — Method of holding lower extremity for application of circular gypsum case in the treatment 
of fracture of the leg. If there is spasm of calf muscles, hold knee flexed. 
Fig. 44b. — Finished gypsum case applied to lower thigh, leg, and foot. 

neath ; and the part should be held by one or two assistants in a corrected 
position, so that the plaster will set without any undue indentations, finger 
marks, or cracking. The rubbing in of additional plaster-of-Paris to the 



TREATMEXT OF FRACTURES 



7o 



outside of the bandage is not advisable, because it does not increase the 
strength of the dressing much, but greatly adds to its weight. All bony 
prominences should be especially well padded, the ringers or toes should 
be left uncovered for examination, and the encasement may be split 



Fig. 45a. 




Fig. 45b. 
Figs. 45a and 45b. — Moulded gypsum splints for fractures about the ankle-joint. 

down on one or both sides immediately after application. The two 
parts should then be held together by a gauze or cotton roller bandage. 
The thickness of the case should depend upon the part to which it is to be 
applied and the amount of strain that may be brought to bear upon it. 



76 



TREATISE OX FRACTURES 



Its wall may be materially strengthened without greatly increasing its 
weight by imbedding between its layers narrow strips of aluminum, zinc, 
or wood at the points where undue strain will take place. If for any 
reason it is deemed advisable not to cut the case immediately after its 
application, it may be readily cut at some future time by moistening the 
line of incision with warm water, vinegar, or water and hydrogen peroxide 
combined. The best instruments for cutting an encasement are a pocket 
knife, a knife with a pruning blade, scissors with serrated edges, 
and saws. 

The best way of using plaster-of -Paris as a fixation dressing in 
open fractures is to apply it in a circular manner and, after the plaster 
has become firm, to cut one or more windows to give access to the site 
of the external wound. If the wound is very extensive and a large window 




Fig. 46. — Moulded gypsum splint for fracture of the metatarsal bones. 



is required, the plaster case may be strengthened by incorporating strips of 
zinc, tin, or iron along the sides of the window ; or the site of the fracture 
may be left entirely free, and plaster cases applied above and below 
may be joined together with suitable metal connections or with specially 
designed wire splints, so as to support the broken bone while leaving the 
wound accessible for frequent dressing with antiseptics. 

At times it may be considered advisable to surround the window 
edges in a gypsum case used for an open, or compound, fracture with a 
covering to prevent its being softened. This may be neatly done by coat- 
ing the edges and plaster near the edges with a solution of rubber in 
chloroform and afterwards shellacking the entire case. This will allow 
frequent irrigation of the wound, and still preserve the integrity of 
the case. 

The great advantages of gypsum splints and encasements are that 
they accurately fit the contour of the limbs or body to which they are 
moulded, and that the materials are cheap and obtainable in all localities. 
All that is essential are a dozen layers of mosquito netting, dry plaster- 



TBEATMEXT OF FRACTURES 



77 



of-Paris powder, and water. These things are to be found in every town 
throughout the civilized world. The surgeon needs only to cut the net- 
ting into pieces, smear them with a paste made of the plaster and water, 
mould them to the patient's surface, let them dry, remove them, trim the 
edges, and he has rigid splints of proper size and shape. 

Extension or Traction Dressings and Methods. — Traction, often 
called extension, has been used in the treatment of certain fractures of 
the extremities for a long time. Its object is to overcome displacing 
muscular spasm by exerting a continuous pull on the fragments. It 
thereby corrects overriding, and, it may be, the lateral and rotary de- 
formities, due to muscular contractions. Its use in the treatment of 
fractures is especially well known in the treatment of fractures of the 




Fig. 47. — Method of applying traction to leg and thigh. The Buck's traction apparatus. Sandbags 
may be placed at both sides of the extremity, or, better, an external T or Liston splint to prevent eversion 
or inversion. Long, narrow boxes to hold bricks on edge are better than sandbags. 



femur. It was first used by Gross in 1830, in the form of an adhesive 
plaster dressing with weights; and later it was popularized by Gurdon 
Buck, whose name has been given in America to this form of dressing 
(Fig. 47). It is usually obtained by fastening to the limb a stirrup 
made of a plate of metal or wood and strips of adhesive plaster. From 
this a cord passes over a pulley to the required weights, which may be 
bricks or pieces of heavy metal. The necessary countertraction is secured 
by utilizing the resistance or weight of the patient's body. During the 
last half century much attention has been paid to treatment of fractures, 
especially of the lower extremity, by traction methods. 

Bardenheuer has claimed that the principal cause of deformity in 
fractures is general retraction of the muscles and other tissues surround- 
ing the lesion in the broken bone, as a result of the blood infiltration of 
the soft parts. Hence occurs a secondary tissue change about the fracture, 



78 



TEEATISE OX FBACTURES 



which is most marked in the muscles and results in contraction and dis- 
placement of the fragments. 

The ordinary methods overcome only the normal muscular contrac- 
tion. Bardenheuer considers that the usual use of weights is not suffi- 
cient, and that extension should be positive and so great that not only 
is the normal muscular contraction overcome, but the contracted muscles 
are permanently stretched. The principles of his method combine traction 
in a longitudinal direction with countertraction, and traction in trans- 
verse, rotary, and oblique directions, as required. By these various 
forms of " extension " he claims to be able to overcome all forms of dis- 
placement, and to obtain not only good functional results, but also good 



Fig 49. 




Fig. 48. — Thos. Bryant's method of vertical traction especially useful in fracture of femur of infants. 
Fig. 49. — Oblique traction used for sub-trochanteric fracture of femur. 



anatomic apposition of the fragments. Bardenheuer employs his method 
of extension in fracture of the upper and lower extremities. The 
method, which uses traction in many directions at the same time, can 
scarcely be used outside a well-equipped hospital. It is complicated 
and requires careful supervision daily by the surgeon in charge. The 
patient is compelled to rest in bed for at least three weeks. It demands 
expensive apparatus and the results are, as a rule, no better than those 
obtained by simpler methods. Judging of the results of Bardenheuer and 
his pupils from a study of his X-ray photographs, one is led to conclude 
that anatomical apposition of the fragments is not as frequent as one 
would expect and that functional results may be unsatisfactory. This 
method has not been popular in American hospitals, probably because 
of the absolute rest in bed enforced in all cases and the careful daily 
supervision required by the complicated apparatus. 



TREATMENT OF FRACTURES 



79 



An important outcome of Bardenheuer's teaching has been the fuller 
recognition of the necessity of securing for fractures careful and frequent 
attention from skilled surgeons ; and therefore the desirability of special 
wards for these injuries in hospitals. The method of dressing is less 




Fig. 50. — Steinmann's method of nail extension shows pin through condyles of femur and 

" ft of " 



traction for fracture of shaft of femur, 



important than the conscientious care of a surgeon with mechani- 
cal instinct. 

The vertical traction method suggested by Thomas Bryant, especially 
for fractures of the femur in children, though it is available for adults 




FlG. 51. — Steinmann's method of nail extension for fracture of the femur. Traction is 
made from a pin driven through the head of the tibia. 

as well, or its modification, oblique traction, in appropriate cases, as 
shown in the illustrations, will often allow the rejection of complicated 
apparatus, especially if the seat of fracture be steadied by coapta- 
tion splints. 

Steinmann's Method of Nail Extension (Figs. 50 and 51). — This 
method was first described by Steinmann in 1907, although it had pre- 



80 TREATISE OX FEACTUEES 

viously been employed by Codivilla in Bologna in 1903. Steinmann 
claims that his method differs from that of Codivilla in that the latter 
uses extension by placing a nail in through os calcis. 

Steinmann secures traction in fractures of the long bones by the 
insertion of a steel nail through the epiphyseal end of the distal fragment, 
and " extension " is made by means of an appropriate apparatus attached 
to the nail. Steinmann employs this method in upper as well as the lower 
extremity. He claims that there is no necessary irritation at the points 
where the nails enter the skin, that no unusual precautions to prevent 
infection are necessary, and that less weight is necessary than that re- 
quired in the extension method with adhesive plaster and a stirrup of 
wood. He states that with the use of semi-flexion even less weight is 
required. Steinmann has used these nails in the os calcis for fracture of 
the malleoli, in the malleoli or through the tibia in fractures of the bones 
of the leg, and in the condyles of the femur for fractures of the shafts 
or neck. Thev have also been used in fractures of the humerus and have 




Fig. 52a. — -Nathan Smith's anterior wire splint. 

been employed by Wilms in the reduction of congenital dislocation of 
the hip- joint. 

The disadvantages of the method are: The possibility of infection, 
by which the nails at times become loosened very rapidly, and the con- 
stant supervision. Cases of infection following its use have been re- 
ported by Anschutz, by Morian, and others. Other disadvantages are 
the possibility of overcorrection with the formation of false joints, the 
possibility of gangrene of the skin at the point of insertion of the nails, 
and the probability of interference with the epiphyseal cartilage and 
subsequent growth of the bone in children. 

Instead of using a long nail through the condyles of the femur a 
nail may be driven into each condyle in an oblique direction. At times 
it may be advisable to use the drill for drilling appropriate holes for the 
nails. To the head of these nails there is attached a special apparatus 
resembling an ice-tongs, and extension is applied directly to this. Ordi- 
nary ice-tongs may be used for the purpose by driving the points of this 
tool into the condylar end of the femur and thus obtaining a hold for 
the cord with weights. During the first week 25 to 30 pounds are 



TREATMENT OF FRACTURES 



81 



used, and later 10 to 18 pounds. Reposition of the fragments usually 
is secured by the sixth day ; in some cases overcorrection or a complete 
diastasis may occur. After reduction the amount of weight may 
be reduced. 

There is no doubt that this method is of especial value in certain forms 
of fracture, where reduction and anatomical apposition cannot be ob- 
tained by other means. The objections to its use are noted above. That 
it is a method for hospital use alone cannot be too strongly stated. 

Traction upon bones which have been broken may be secured by 
the suspended anterior wire splint devised many years ago by Nathan 
Smith (Fig. 52a), of Baltimore, or its modification suggested by Hodgen, 
of St. Louis. 

Traction splints, made for treating tubercular arthritis of knee or 
ankle, also may be adopted for securing rigidity and " extension " of 
fractures of the bones of the lower extremity. The Thomas splint has 




Fig. 526. — Types of Thomas splints and adjustable parts for fracture of femur. 

been much used by army surgeons, for this purpose, in the recent Euro- 
pean War. 

Pott, in 1768, laid stress on the fact that often fractures could be 
relieved of their deformity by postures permitting relaxation of the dis- 
placing muscles. By thus keeping the joints adjacent to a fracture in the 
position which will relax the muscles liable to spasmodic contraction the 
surgeon may prevent deformity in the union. Various appliances have 
been devised to utilize this principle. In association with traction, and 
such support as is needed to obviate displacements due to gravity, this 
postural method of treating broken bones has accomplished anatomical 
reconstruction of the bone. 

The Nathan Smith heavy wire rectangular splint takes advantage of 
this fact. It was intended to be bent to fit each patient, and to keep the 
hip, knee and ankle-joints partially flexed when used on fractured femurs. 
The angles could be readily changed and the point of suspension from 
which the splinted limb was hung altered to obtain traction in varying 
directions. The time and skill needed for the first dressing has probably 
been the cause of its being almost forgotten by surgeons. 
6 



82 



TREATISE OX FRACTURES 



The Hodgen suspended splint is similar to the Smith splint in prin- 
ciple and has been used a good deal in recent years by men familiar 
with its advantages. The weight of the patient is used for countertrac- 
tion in these suspended splints. 

The Thomas splint, used for obtaining traction in fracture of femur 
or of bones of the leg, gets its countertraction by pressure of its pelvic 
ring against the tuberosity of the ischium and the flaring surface of the 
ilium. The traction is obtained through the attachment of the foot to 
the footpiece of the splint. 

The principles involved in these appliances for fractures of the lower 




FlG. 53. — Zuppinger s method of traction and support for fracture of the femur. 

limb may be used in dressings for the upper limb by modifying the shape 
of the apparatus. 

The Bradford frame, so successfully used to obtain fixation and 
traction in joint diseases of the hip and knee in children, may be adopted 
for treatment in fractures of both children and adults. 

Sir Robert Jones, of Liverpool, has called special attention to the 
advantage of using apparatus like the Thomas splint and Bradford frame 
for continuous traction or fixation in the treatment of fractures. He 
believes that fracture dressings like the Buck's extension with weight 
and pulley, which depend upon the weight of the body for counter- 
traction, too often become relaxed and therefore are liable to allow over- 
riding of fragments to occur. 



TREATMENT OF FRACTUKES 83 

If it be true that the overriding of fragments, common in fractures of 
the shaft of the femur and sometimes seen in oblique fractures of the 
humerus, is chiefly caused by muscular spasm due to pain, rest in bed with 
moderate traction and countertraction by the Buck's method would seem 
to be all that is necessary. Such treatment, especially if aided in the first 
week by anodynes to relieve nervous apprehension and pain, has seemed 
to some surgeons to be preferable and sufficient. Perhaps the employ of 
continuous unrelaxed traction, as given by the Bradford and Thomas 
appliances, demands less supervision in the nursing. It has seemed to 
some surgeons that sufficient weight to prevent spasm of displacing 
muscles with the adoption of the postural method of relaxing these struc- 
tures will often be followed by good functional and anatomic cures. 

Lucas-Championniere's views as to the use of posture, the adoption 
of early mobilization and careful massage, to restore the integrity of the 
soft parts and relieve pain, have had a marked influence on the treat- 
ment of fractures in America. 

Zuppinger's apparatus for traction and supp6rt of the lower limb 
utilizes the principles of relaxing muscles and being satisfied with moder- 
ate traction on the broken bone. It has a base board and a method 
of supporting the thigh and leg in various degrees of flexion. 

When fracture dressings for either the upper or lower extremity re- 
quire suspension, a gallows across the bed or a hook or pulley in the 
ceiling may be used. A dependent rope, to be shortened or lengthened by 
an appropriate slide, will permit an easy change in the degree of elevation 
or the amount of flexion of the joints near the fracture. A more expen- 
sive arrangement like the Balkan frame may be used, or any other device 
with the required hooks, pulleys and weights substituted.. 

Massage axd Passive Motion in the Treatment of Fractures. — 
Recent experience in the treatment of fractures and the knowledge gained 
by X-ray observations are making radical changes in methods of treat- 
ment, and have greatly modified preconceived notions regarding the 
pathology and treatment of fractures. Surgeons are now abandoning 
prolonged immobilizing dressings, and in their place are using methods 
of treatment which allow a better circulation, less muscular compression, 
early careful massage, and earlier joint motion. Dressings are not so 
cumbersome, they are changed more frequently, the muscles are more 
frequently masseed, so that by the time good firm union has taken place 
the muscles and joints are in more nearly normal condition. With in- 
frequent dressings and prolonged immobilization, loss of muscular tone, 
muscular atrophy, restriction of the normal motions of the joint and 
undetected deformity are quite common. Massage hastens the absorp- 
tion of exudate, prevents stiffness and atrophy of muscles, and main- 
tains a more normal condition of the circulation. Daily removal of 
splints and light massage, if carefully performed, will be beneficial. 

In addition, slight passive motion of the joints in proximity to the 



84 TREATISE OX FRACTURES 

seat of fracture should be made frequently during even the early days 
of treatment. Light massage and passive motion should be started in 
suitable cases immediately. During the manipulations the part should 
be carefully held by an assistant. The motions at first should be very 
gentle, short in duration, without pain. 

Later, when the callus has become firmer, the interval of time may 
be increased and the massage may be more energetic in character. At 
no time should the manipulations be violent enough to produce displace- 

Fig. 54a. Fig. 546. 



i 




Fig. 54a. — Skiagram of fracture through the surgical neck of the humerus with separation of the greater 
tuberosity. The fracture had been "set" and splintage applied the previous day. The only apparatus 

used after first twelve hours was a linen sling. Treatment ry massage and mobilization (Mennell)._ 

Fig. 54b. — Same case five weeks later. The patient complained of pain and weakness while whitewashing. 

Strength was restored ten weeks after accident (Mennell's Treatment of Fractures). 

ment of fragments. Voluntary motions should be encouraged, and 
dressings may be, in many cases, so applied as to permit of muscular 
movement without doing any damage to the position of the fragments. 
In cases of fractures involving joint surfaces this early massage, and 
especially passive motion, are of the utmost importance. By their use 
the surgeon may obtain quite a wide range of motion, which would be 
impossible with other methods. The only danger to early massage and 
passive motion is displacement of fragments. This should always be 
borne in mind, and there are certain classes of fractures where this danger 
is practically negligible. The massage should not be the vigorous form 



TEEATMEXT OF FEACTUBES 85 

often used by professional masseurs for other purposes. Gentleness 
must be its chief characteristic. The principle of early massage and 
passive and active motion in the treatment of fractures had for its ex- 
ponent Lucas-Championniere. For many years he advocated these 
methods, and recommended the discarding of splints to a great extent 
in fracture treatment. He was an earnest opponent of prolonged im- 
mobilization ; and may perhaps have been led to take an extreme position, 
because he saw the bad functional and bad anatomical results due to it. 
His views are of great value. Every surgeon who wishes to do justice 
to fractures of the limbs should take the time to become familiar with 
the results obtainable by the adoption of measures similar to those advo- 
cated by Lucas-Championniere and his English disciple, Dr. James B. 
Mennell, of St. Thomas's Hospital, London. The latter' s book on " The 
Treatment of Fractures by Mobilisation and Massage " will be 
most serviceable. 

Early light massage, early passive and active motions, with compara- 
tively simple external fixation apparatus, will usually give better results 
than the immobilization method as used by many practitioners. It is 
the adherence to the antiquated immobilization method without passive 
and active mobility which has given Lane and his followers their chief 
argument in favor of almost universal treatment by plates and screws. 

Functional Treatment of Fractures. — By the functional treat- 
ment is meant the use of all means which will preserve the circulation, 
retain normal muscular tone and joint function, and help in early callus 
formation. It seems probable that in many instances immobilization is 
too absolute, the use of the fixation dressing too prolonged, and proper 
supervision of the fracture greatly neglected. It is believed that there 
are many fractures which, if properly reduced, will remain in correct 
anatomical position with a minimum of splinting. In conjunction with 
shorter periods of immobilization and less cumbersome dressings, the 
functional recovery of the part should be perfect by the time good bony 
union of the fragments has occurred. This often may be accomplished 
by early light massage with passive and active motion. What can be done 
thus is seen in the treatment of the classic fracture of the lower end 
of the radius conducted on these lines. Complete reduction, fixation 
upon a contour splint, which does not limit voluntary flexion and exten- 
sion of the fingers, combined with light massage and occasional passive 
as well as voluntary movements of the wrist from the beginning, and dis- 
carding the splint at the end of two and a half weeks, will seldom fail 
to result in five or six weeks in a good functional and anatomical cure. 
Deformity of the radiocarpal region after impacted fracture, in which 
extension and flexion of the wrist are limited, and in which there is 
marked abduction of the hand combined with cedema of the wrist region 
and stiff fingers, would be very infrequent. It is adherence to old ideas 



86 TREATISE OX FRACTURES 

of the pathology of this injury and unscientific clinging to prolonged 
immobilization that give rise to the bad results so often seen. 

In addition to the suggestions made above, there are other means of 
improving the function of the part, such as electricity and hot- water 
bathing and, in delayed union, congestive hyperemia locally. Appro- 
priate treatment for general conditions, such as tonics, thyroid extract, 
antisyphilitic remedies, in those showing a positive Wassermann reaction, 
with fresh air and sunlight are useful. Frequent errors in hospital prac- 
tice are the omission of morphia and atropia to relieve pain and muscular 
spasms, the neglect to quiet the patient's mental perturbation with bro- 
mides, and to insure him prolonged sleep the first two or three nights 
after the receipt of the injury. 

The use of passive hyperemia by means of a rubber bandage about the 
limb in cases of delayed union in fractures was employed by Roberts 
and its results published in 1898, and also by Helferich in 1887. Both, 
it is believed, anteceded Bier in using it in fractures, although he was 
using it in other conditions in 1892. 

Ambulatory Treatment oe Fractures. — The advisability of 
allowing patients to walk during the treatment of fractures of the lower 
extremity depends upon several factors. There are fractures in which 
the ambulatory method is clearly contra-indicated ; on the other hand, 
there are many, especially of the upper limb, which may be treated in 
this way without imperiling an expected good result. Again, there are 
certain cases in which the treatment of the fracture by any formal method 
is of secondary importance, because the danger of impending complica- 
tions interrupting the recovery or ending the life of the patient is of 
greater moment than the securing of a good cure of the fracture. The 
disadvantage of the ambulant method of treatment is difficulty of proper 
application of the required retentive dressing, and its careful super- 
vision when the patient is not kept quiet in bed. Complications arising 
at the seat of fracture are more frequent; it is a form of treatment not 
suited for the general practitioner ; in many fractures it is impossible to 
maintain reduction of the fragments if the patient is moving about on his 
feet. Therefore, in these injuries of the lower limb, ambulatory exercise 
may only be used with safety at the end of several weeks, when union is 
becoming firm. As a subsidiary form of treatment it is often convenient, 
comfortable and safe. 

The advantages of ambulant treatment may be summarized : Pul- 
monary complications are less, even in the aged ; delirium tremens is not 
so frequent; muscular atrophy and rigidity of joints are not so great, and 
callus formation is very abundant and rapid. These remarks apply espe- 
cially to fractures of the lower limb. It is distinctly contra-indicated as a 
rule in fracture of the femur until at least the third week, and in fracture 
of the shafts of the bones of the leg until the same time has elapsed. 
After this time it may be used if it is possible to maintain good apposition 



TREATMENT OF FRACTURES 87 

of the fragments by an appropriate external dressing - . When fractures 
are fixed by plates and screws, the ambulant method may be instituted 
earlier as a part of the management of the injury. In fractures about the 
ankle-joint, this form of treatment may be used from the beginning, or 
at least at the end of four or five days. In fractures of the humerus it 
may generally be used, even in cases requiring extension. About the 
only cases that prohibit its use are fractures of the surgical neck of the 
humerus requiring extension in the abducted position. In a great major- 
ity of cases not requiring extension, the best and cheapest form of dress- 
ing will be the plaster-of-Paris case and crutches. In those cases requir- 
ing extension there are many well-recognized and appropriate forms of 
traction braces obtainable; and their number may be supplemented by 
specially constructed ones to suit the particular fracture under the sur- 
geon's care. The Thomas splint for the thigh and similar metal extension 
splints for the arm are available. They have been much used recently 
as a result of military experience. Indeed, the European War has done 
much to improve the treatment of closed as well as open and in- 
fected fractures. 

Wearing the sole of the shoe of the well leg one inch higher than that 
on the injured limb and using long crutches will permit the patient to 
walk in the open air without risk of bearing weight on the seat of fracture. 
Keeping the foot of the unsound limb off the ground may be secured by 
flexing the knee of the injured side by means of two leather straps around 
thigh and calf, fastened together with a short strap under the popliteal 
space, or by holding the knee of the uninjured limb flexed in a movable 
gypsum encasement. Then it is not necessary to raise the other shoe 
or lengthen the crutches. Early resumption of exercise is often neglected 
when easily practicable by such devices. 

Functional relaxation of displacing muscles, plastic contour splints, 
properly applied traction, judicious mobilization and massage associated 
with a knowledge of anatomy, a mechanical sense and assiduous atten- 
tion are the requisite therapeutic and professional elements for non-opera- 
tive management of broken bones in the extremities. Simplicity in 
fracture dressings is of importance. If elaborate apparatus is required, 
the patient would probably be better served by the operative method of 
direct fixation at the hands of a skilled expert in surgery. 



CHAPTER IV 

TREATMENT OF OPEN AND INFECTED FRACTURES 

Fractures uncomplicated by wounds overlying the seat of the break 
are not likely to be followed by a septic local osteomyelitis. Danger to life 
scarcely exists except when simultaneous damage has been done to adja- 
cent structures. Repair by union of the fragments is usually to be ex- 
pected early. Such fractures are termed closed or simple fractures. 
Complicated fractures are those in which severe wounds, dislocation, joint 
injury, or lesions of vascular, nervous or visceral tissue coexist. 

A common complication of fractures, especially in industrial and mili- 
tary injuries, is coexistence of wounds of the overlying soft parts per- 
mitting easy admission of infecting material to the medullary constituents 
of the bone. Such complicated fractures are called open or compound 
fractures. They are more difficult to treat than closed fractures unless 
the communicating wound from skin surface to the site of fracture can be 
closed before infection sets up a septic osteomyelitis. 

Open fractures may be divided into four classes : ( i ) those in which 
there is not only great pulpefication and destruction of bone, but also 
crushing and devitalization of the surrounding soft parts; (2) those in 
which there is comminution of bone, moderate injury of soft parts, with- 
out interference with the main blood supply, and a small external wound ; 
(3) those in which there is a fairly large wound, perhaps near the joint, 
and in addition protrusion of one or more fragments through the wound 
with considerable soiling of their ends; and (4) those in which there is 
only a small external wound with very little soiling of the depths of the 
wound, though the opening through the soft tissues goes down to the 
break in the bone. 

In the first class amputation may be the only thing to do. As a 
rule there is interference with the main blood supply to the extremity, 
the soft parts are widely devitalized, and the entire wound so soiled 
that it is impossible to render it sufficiently aseptic to expect union. Such 
injuries require amputation, or should be treated as septic osteomyelitis 
complicated by fracture. 

In the three other classes of open fracture a great deal can be done by 
conservative surgery. The skin should be shaved and washed with 
soap and water, and great care be taken not to contaminate the depths of 
the wound. When the surgeon feels sure that contamination has taken 
place the wound should be thoroughly irrigated with a 2 to 5 per cent, 
alcoholic solution of iodine. The wound and surrounding skin should 
then be cleaned with ether or alcohol, and the wound, if large, par- 
tially closed, and drainage, in the form of folded rubber tissue, introduced 



TEEATMEXT OF OPEX AXD IXFECTED FEACTURES 89 

to its bottom. A dry sterile dressing should then be applied and the part 
immobilized in a plaster-of-Paris case, in which a window has been cut 
over the seat of drainage. Unless there is some indication of trouble, 
such as continued fever, pain, or a feeling of local heat, the wound should 
not be dressed for several days. If there is any indication for examining 
the wound it should be uncovered at once, and, if found infected, thor- 
oughly disinfected by antiseptic applications, such as solution of dichlor- 
amin-T or tincture of iodine. If pus is present, the wound should be 
freely opened for drainage, and irrigated. 

Reduction and fixation of the fragments should be carried out in the 
usual manner ; but provision must be made in applying splints for access 
to the wound, so that it may be properly treated. Rapid healing will 
allow the injury to assume the characteristics of a closed fracture. In- 
fection of the wound in the soft structures, unless prompt disinfection 
is secured, may lead to osteomyelitis, burrowing of pus and general septi- 
caemia. A fracture with an open wound leading to the site of break in 
the bone must be kept from infection or the infection must be controlled 
as quickly as possible. At the same time coaptation must be secured 
and maintained. 

Treatment to prevent infection gaining access to the lesion in the bone 
must be instituted at the earliest possible moment. If the opening in 
the skin, which is the protective armor of the man's body, is small, imme- 
diate disinfection of the lips of the wound and the surrounding skin with 
an antiseptic is imperative. Watery solutions, unless sterile or actively 
germicidal, may carry infective organisms into the depths of the sterile 
wound and be harmful. Sometimes, therefore, if the attendant circum- 
stances encourage the belief that the interior of the wound has not been 
contaminated, tincture of iodine painted around the wound, without 
previous use of water and soap, is all that may be necessary prior to 
using a sterile gauze dressing The iodine in other cases should be 
carried just within the lips of the wound by means of a small swab of 
sterile cotton on a sterile applicator of wood or metal. Should the 
wound be already probably infected to its depth, a scalpel should be 
used to open it freely to permit the thorough application of the iodine 
or other germicide to its raw surfaces. Sometimes, after the skin 
has been sterilized, with the wound itself kept covered with a sterile 
or antiseptic pad, a dry antiseptic powder may with propriety be sprinkled 
over the opening of the skin. This, if left undisturbed, will become a 
sterile scab under which the wound will heal promptly. 

Promptness and thoroughness in disinfecting large, irregular con- 
taminated wounds are essentials of success. Small openings in the skin 
often conceal vast mutilation of the soft parts by the pulpefying effect 
of the injury, movements of the fragments of broken bone or the multi- 
plicity of foreign bodies carried into the damaged tissues. Military and 
industrial accidents are especially vicious in thus causing contamination 



90 TEEATISE OX FEACTUEES 

and infection of fractures. If disinfection is not immediately secured 
with thorough removal of dirt, gravel, missiles, particles of clothing and 
filth, the fractured bone is sure to become the seat of septic osteomyelitis. 
A few hours will cause the infective organisms to multiply in the blood 
and other albuminous fluids and contamination will become infection. 
Local infection may later become a general septicaemia because of the 
difficulty of obtaining thorough drainage and antiseptic treatment of 
the vital structures within the bone canals and lacunae. 

General anaesthesia to permit wide exposure by incisions of the frac- 
tured bone, removal of foreign bodies, opening irregular pockets and 




Fig. 55a- — Through-and-through wound. i, Small opening of entry; 2, large 
opening of exit; 3, extensive fragmentation of bone; 4, bone fragments scattered 
in damaged tissue; 5, shreds of _ clothing stopped by the aponeurosis and at 
entrance in bone cavity. (Loewy.) 

excision of devitalized tissues will often be necessary. Such radical 
treatment will save many limbs, indeed many lives. 

" Debridement," as used in war wounds, is more necessary in bad 
comminuted and contaminated open fractures than in more extensive 
wounds of the same character in the soft parts alone. The value of such 
operative removal of damaged soft parts in permitting primary closure 
or delayed primary closure of wounds must be recognized in civilian 
practice. The bacteriological control of Carrel will be of great service 
to civilian operators. 



TEEATMEXT OF OPEX AND IXFECTED FRACTURES 91 

Bracketed splints and apparatus to maintain apposition of fragments 
must be so applied to infected fractures that the needed observation and 
local treatment may be possible. Antoine Depage of the Belgian army has 
had much experience in treating infected fractures received in warfare. 
He advocates immediate trimming away of all damaged tissue liable to 
furnish a good soil for microbic growth, extraction of every foreign body 
found within the widely laid open wound and absolute haemostasis. Bone 
splinters which seem to be still uninfected are allowed to remain with 
the larger fragments. 

The Carrel instilling tubes are then inserted into the depths of the 
wound, which is irrigated every two hours with Dakin's neutral solution 
of sodium hypochlorite. The dressings of gauze wetted with the solu- 
tion are changed daily and the surfaces cleansed with lavage with sodium 
oleate. The results of this method of disinfection are determined every 
day by careful bacteriological examination of the excretion from the 
wound surface. When the smear is negative for two or three successive 
days the wound is closed over the broken bone with sutures. Scar edges 
are trimmed away, but granulations left undisturbed, if the disinfection 
has been acquired long enough to permit such changes in edges or surface 
of the wounds. Closure to be complete will, in some cases, require trans- 
fer of pediculated flaps of skin and superficial fascia or the use of 
Thiersch skin shavings. External fixation of the fracture is employed 
during this treatment. 

The gunshot fractures seen in civilian practice will often be scarcely 
at all contaminated and may not need such radical treatment. In some 
open fractures caused by pistol shots or rifle bullets with moderate velocity 
the missile will make a practically sterile track through the soft tissues 
and the bone. Then if no soiled clothing is carried into the wound, such 
fractures will probably need only sterilization of the surfaces about the 
wound and an antiseptic gauze dressing to absorb and sterilize the oozing 
blood and serum. The bullet need not be removed, unless it after a few 
days causes high temperature, pain or swelling, indicating infection along 
the bullet's track. Splints to retain the fracture may be applied to the 
limb. These must be such as to enable the surgeon to uncover the 
wounds of entrance and exit to inspect, or incise, and drain, should deep 
infection become evident. 

Open Fractures. — Infected open fractures, especially the severely 
infected cases found in warfare, need immediate thorough disinfection, 
if it has not been done previously, with the Carrel-Dakin instillation 
method of using neutral hypochlorite solution ; unless this disinfection is 
unnecessary because of early excision of contaminated or partially de- 
vitalized tissue. 

Pierre Duval reported at one of the recent congresses of the American 
College of Surgeons that open fractures so treated had been brought 
to a condition in which primary closure could be obtained in about 50 
per cent, of cases. 



92 



TREATISE OX FKACTTTKES 



It must be remembered that artillery wounds causing open fractures 
are very different from the gunshot fractures produced by rifle bullets 
at long range, shrapnel, or pistol bullets. These are allied in nature, 
so far as surgery is concerned, to gunshot wounds treated in civil life. 
The open fractures obtained in industrial accidents and railroad casual- 
ties, however, resemble very much the mutilating injuries of modern 
warfare, and demand treatment very similar to the methods employed by 
military surgeons. If seen within twelve hours after the receipt of injury 





Fig. 556. — r, Position of path of missile at time of injury; 2, position of path of missile at time 

of operation. (Loewy.) 

and if there is at the time no incipient suppuration or sloughing yet 
apparent, it may be assumed that contamination is still localized. The 
localization may be at the surfaces of the devitalized soft tissues and in- 
jured bone, and around the embedded foreign body and portions of cloth- 
ing, which have been driven into the tissues in the vicinity of the fracture. 
Prompt operative intervention is important in such injuries, unless shock 
or hemorrhage has depressed the patient to a point sufficient to threaten 
death, even if the insult to the tissues will be increased by the surgeon's 



TEEATMEXT OF OPEX AXD XXFECTED FRACTURES 93 

efforts. The operative attack in patients almost moribund must be delayed 
until the shock or anaemia has been controlled. 

An exception to this operative rule may be that an infected focus, 
without sufficient opening for drainage, or the appearance of symptoms of 
incipient sapraemia or septicaemia already present, may demand incision for 
drainage. It will be seen that such operative incisions do not require time, 
prolonged anaesthesia or even such transportation as would be demanded 
if thorough excision of tissues and more elaborate disinfecting procedures 
were required. The complete excision operation or elaborate disinfec- 
tion, demanded in contaminated infected fractures, must be postponed, 
therefore, in patients reaching surgical aid while in shock or profound 
anaemia from bleeding, until the further traumatism becomes safe. 

If a focus of inflammation is evident, evacuation of pus or fluids 
almost purulent may be proper to relieve tension and septic absorption ; 
but deep explorations for removal of devitalized bone splinters, long 
operations to thoroughly cleanse wounds, and thereby opening up new 
spaces for absorption and septicaemia, are improper. At this time 
also it is unwise to undertake wiring or plating the fracture for fixation, 
or making wide excisions of the damaged tissues. Immobilization of the 
fracture is important because venous and lymphatic canals are opened, 
thrombi displaced, and spreading of septic processes encouraged by move- 
ment. Hot antiseptic packs about the wound on the outside of the limb 
and efficient provision for drainage to encourage discharge of infected 
fluids are the life-saving measures. Direct fixation of fractures, excision 
of sloughs, should be delayed until local conditions are more favorable. 
Delayed primary closure may occasionally be attempted after disinfection 
has been established. It is wise, however, not to* do this unless the surgeon 
has wide clinical experience in such cases or has the bacteriological condi- 
tion of the wound reported to him almost daily. 

When the suppurative stage has been an active process for some weeks 
•because the open fracture has not been seen soon after its occurrence, or 
for any reason has not been efficiently treated, there will be found sinuses 
leading down to the seat of fracture or to pockets of pus which have 
spontaneously obtained evacuation through the soft tissues. The sinuses 
have formed at the points of least resistance. Joints may be invaded 
by the suppurative inflammation and add to the danger of general septi- 
caemia. Through some of these sinuses the instillation tubes of the Carrel- 
Dakin method may be carefully inserted and the sodium hypochlorite 
run in every two hours, to neutralize the toxic fluids incarcerated in the 
tissues. If this method of disinfection fails to prevent continuance of 
the pyogenic risk, more active surgical intervention becomes important. 
The openings must be enlarged, pus pockets opened, necrotic pieces of 
bone taken out and through-and-through drainage established. These 
local measures with external support rather than internal fixation are 
the surgeon's main reliance. 



94 TREATISE OX PKACTUEES 

General treatment in the way of tonics and nourishing food -at fre- 
quent intervals and care of the bodily functions are of much moment 
under these circumstances. 

The surgeon should remember that in the treatment of all open frac- 
tures, whether received in war or in industrial or other casualties, closure 
of the wound before infection has followed contamination is the secret 
of success. If circumstances prevent prompt closure, the contamination 
will cause infection. Then this must be combated and closure obtained 
as early as possible. 

If the wound is small and contamination not very likely, closure may 
be effected by cleansing the surfaces surrounding the small wound and 
immobilizing the broken bone and the soft structures. 

If contamination has occurred, excision of the contaminated tissues 
under anaesthesia, and primary suture are the approved steps of treat- 
ment, provided this can be done within about 12 or 15 hours, and the 
patient is strong enough to bear the operative attack. 

If the patient has lost blood, suffered shock, or been without food, 
or transported a long distance, the surgeon should improve the general 
condition, immobilize bone and soft tissues, and later excise devitalized 
structures, close wound and fix fracture by external appliance. 

If suppuration or sloughing has already begun, careful disinfection 
without disturbing parts too much may be tried. This, if ineffective, 
should be followed within a few days by incisions for free drainage, 
external fixation, rest and supporting treatment. 

If the patient is received at a later period and local septic conditions 
have advanced to the point of gangrene of soft parts, necrosis of frag- 
ments, and sinuses leading to pus pockets, the patient should be subjected, 
when his condition permits, to a thorough exposure of pus pockets and 
necrotic areas; followed by removal of dead bone and fixation, with the 
hope of obtaining union and closure of the wound by the granulating- 
process. It is too late then to try either primary or delayed primary 
closure; and direct fixation of bone by screws, wires, plates, or grafts 
should not be attempted. External fixation with provision for obtaining 
a sterile condition of the wounds will be required. 

Bone grafting should be delayed for a good many months after clos- 
ure of a wound the seat of septic processes ; otherwise the operative inter- 
vention is almost certain to revive the activity of enclosed microorganisms. 
Deformed union and non-union of infected fractures should, therefore, 
be let alone for from three to six months, lest the operation for cure be 
imperiled by revival of infection. 

Dr. G. Loewy. in speaking of Avar fractures which are open, says 
very truly that these war injuries should be treated as emergencies, like 
strangulated herniae. By this he means that early attention and immediate 
disinfection of the wound and the fracture itself should be undertaken 
by the surgeon. He recommends when possible a preliminary X-ray 




Fig. 55c. — Modification of the so-called Balkan frame used by Lyle to obtain balanced 

suspension of the leg. Instillation of neutral hypochlorite solution is being used in an 

infected open fracture of tibia and fibula. (Courtesy of Dr. H. H. M. Lyle.) 



One of the satisfactory results of the World War has been to cause a due apprecia- 
tion and a usual application of the doctrine of Lucas-Championniere relative to the value 
of early mobilization of joints and the care of overlying soft structures in treating frac- 
tures of the extremities. 

Suspension combined with traction, less exactly called " extension," has also been 
accepted with general approval. Both of these measures were insisted upon in the first 
edition of this Treatise and in the Report in 1913 of the Fracture Committee of the 
American Surgical Association. 



TBEATMENT OF OPEN AND INFECTED FRACTURES 95 

examination to determine the main line of fracture and to obtain the 
localization of buried foreign bodies. It is Loewy's belief that fluoroscopy 
is usually sufficient for the first examination, but that radiographs later 
are likely to be necessary to prove the existence of fine fissures in the bone 
and small displaced splinters. 

In such war fractures he advises removal of fragments entirely de- 
tached from the main bone, mechanical disinfection of the focus, and 
the establishment of free access to the medullary canal. He lays stress 
upon this last indication of treatment because small fragments may have 
been forced into the medullary canal ; doubtless also because he fears that 
a focus of infection may exist therein and supply cause for later pyogenic 
changes in the depth of the wound. 

Pieces of clothing are liable to be forced by missiles into the tissues, 
and are usually stopped at the openings in the fascia or by the roughened 
ends of bone fragments. Fie advises that infectious material of this sort 
should be carefully looked for at the points just mentioned. Any open 
fractures contaminated, whether by war injuries or industrial injuries, 
should undoubtedly have in the main the treatment recommended by 
Loewy. His idea, of course, is to cut away devitalized tissue, when pos- 
sible, before starting the disinfection with Carrel hypochlorite of sodium 
solution. The incisions to do this need not necessarily begin at the wound 
of exit or of entrance of the missiles, though these orifices should be 
thoroughly inspected for foreign bodies, such as clothing, and for portions 
of missiles or dirt driven in at the time of injury. The operator who 
undertakes to prepare such a wound for primary closure after excision of 
tissue or disinfection should injure or disturb muscles, nerves and 
vessels as little as possible, but must have the incisions and excisions suf- 
ficiently efficient to afford easy access to the medullary canals. 

It is probably seldom wise to suture or plate fragments at the time 
of the primary dressing of an open fracture. General anaesthesia should 
be the rule when cleansing and reducing severe open fractures, because 
unless the disinfection is thorough and the reduction of fragments satis- 
factory the convalescence will be long and the anatomical result poor. 
The primary dressing of an open fracture determines usually the fate of 
the patient. If asepsis is obtained, the injury progresses almost like a 
closed fracture. Otherwise prolonged suppuration is probable; and 
death or amputation not unlikely. If large hematomas are present, they 
may be opened. If the ends of fragments are contaminated, they should 
be thoroughly cleaned with antiseptics, or perhaps excised. Portions 
of bone with attached periosteum should be left intact, Operative inter- 
ference for fixation of fragments performed at this stage is likely to 
increase the gravity of the injury. The wounds are more or less contami- 
nated, and while in many cases the infecting organisms may not be viru- 
lent, in some the forms of infection are extremely so. Operative exten- 
sion of the infected wound may, by opening up new paths of infection. 



96 TEEATISE OX FBACTT7BES 

lead to disaster. If bone suture or other methods of direct fixation 
have to be employed, it may be well to wait a week or more. Conserva- 
tive treatment, if there is good circulation of the part, should take care 
of many organisms, and more perfect reduction may be gained by later 
operation. The most frequent forms of infection are virulent strains 
of streptococci, Staphylococci aureus and albus, tetanus bacilli, and 
Bacillus aerogenes capsulatus. The European War has furnished 
many examples. 

A very important step in the treatment of open fractures badly con- 
taminated with street dirt may be the prophylactic use of antitetanus 
serum. When circumstances have prevented thorough disinfection of 
the wound soon after its receipt, a subcutaneous injection of 1500 to 3000 
units of the serum may be given as a routine measure. Many open 
fractures, however, are received under conditions that make them no more 
likely to be infected with tetanus bacilli than other wounds. Those which 
have been soiled with earth liable to harbor tetanus microorganisms 
should be viewed with suspicion. This is the case with gunshot wounds 
received in trench war. 

The use of metal plates or other forms of internal fixation is not 
advisable at the time of primary dressing. In open fractures, direct 
fixation of the fragments to obtain anatomical alignment probably should 
be used only at a later period, when the pyogenic or other organisms 
have less opportunity to exert harmful influence or when it is evident 
that malunion is taking place. They should not be used in the presence 
of marked infection. Direct fixation of the fragments may work harm 
because of probable secondary infection of the tissues, especially of bone. 

The length of time required for operative fixation, the lowered resist- 
ance to septic microorganisms characteristic of partially devitalized soft 
tissues, and the damage from stripped up periosteum, already sustained 
by the broken fragments, make severe osteomyelitis and general sepsis 
likely to follow imbedding foreign fixation materials. 



CHAPTER V 

THE OPERATIVE TREATMENT OF CLOSED FRACTURES 

The treatment of fractures had not received, by the general surgeon. 
prior to the European War, the attention that it deserved. Abdominal, 
pelvic and cranial surgical conditions and their management had been of 
utmost interest ; but the surgery of fractures was committed largely to the 
junior officers of hospitals and not viewed as a special subject of study 
by surgeons. Orthopaedists had developed the surgery of joints, tendons, 
and deformities, but the profession at large had been content with the 
teaching of twenty years ago in regard to the treatment of fractures. 
Good functional results were the subject of congratulation. Real ana- 
tomical apposition of the fragments was not considered necessary in frac- 
tures. If the patient had a fair functional result and a not too evident 
deformity, the anatomical position of the fragments was often disre- 
garded. The development and perfection of radiography have shown 
how poor such work has been. It has taught that perfect anatomical 
apposition of fragments was rarely obtained except in children, that 
exuberant callus was a frequent condition, that many text-book methods 
of treatment of certain fractures were obsolete and were at times harm- 
ful, that the lines of fracture were not always as they were thought 
to be, and that many supposed sprains and contusions, about joints 
are fractures, sprain-fractures, or avulsion of tubercles and mus- 
cular attachments. 

The Rontgen ray, in addition to helping in diagnosis, is of great value 
in the subsequent treatment. By it surgeons are able to judge of the 
continued coaptation of the fragments, of the amount of callus produced, 
and of the extent of union present. The use of the Rontgen ray is wise, 
not only in cases of suspected fracture; but the majority of sprains, so 
called, should be radiographed. By making this the customary rule, 
one not only is able to make a better and clearer diagnosis and use more 
intelligent treatment, but a great many supposed sprains will be found 
to be fractures. This is particularly so of injuries about the wrist-joint. 
Many fractures of the small bones, particularly of the carpals, and unsus- 
pected sprain-fractures will be recognized. In taking radiograms of sus- 
pected fractures it is advisable to have a primary radiogram made before 
reduction, one immediately after reduction, and a third about one week 
to ten days after the time of reduction. At each X-ray examination 
two radiograms should be made, one at a right angle to the other, so that 
the existence of a fracture and the position of the fragments may be 
recognized. An anteroposterior and lateral view should thus be made, 
when feasible. 

7 97 



98 TEEATISE OX FBACTTKES 

The dangers of infection of bone in the open treatment of closed 
fractures have been a constant menace to surgery and have been dwelt 
upon in text-books for years. Yet operations on tumors of bone and 
exostoses, and osteotomies for osteomyelitis and periostitis have been 
unhesitatingly performed. That this teaching has been fallacious is 
shown by the results obtained to-day in all classes of bone surgery per- 
formed under the proper aseptic precautions. While infection of bone is 
a serious condition, it should not follow a properly performed operation 
in cases of fracture any more frequently than after abdominal operations 
or procedures on other structures. The risk, however, is much greater 
than in peritoneal surgery. When septic processes occur in open frac- 
tures or in closed fractures, subjected to fixation by incision, the dangers 
to limb and life are great; because the infectious pus is apt to be locked 
up in the medullary canal. Free opening of the overlying soft tissues and 
chiselling a wide channel into the marrow cavity for drainage is impera- 
tive. Gunshot fractures give evidence of the need of this prompt pro- 
vision for bone drainage in suppuration complicating broken bones. 

From experience it may be stated that the cases of fracture requiring 
operation are comparatively few. There are certain closed fractures 
which always call for operative interference, and there are some which 
are followed by better anatomical and functional results by operative 
fracture treatment. Open operation has long been used to cure non- 
union, vicious union in old fractures, and in those recent cases in which 
failure of the usual methods of reduction has occurred or the use of 
approved appliances to retain the fragments of bone in apposition has 
resulted in failure. The cases most urgently requiring operation are those 
in which the deformity cannot be reduced, or, if this is possible, in which 
proper approximation cannot be maintained; severe open and infected 
fractures ; comminuted fractures in which it is impossible to properly 
replace the fragments; and instances of non-union, mal-union, and exu- 
berant callus. In many cases in which there is marked comminution of the 
fragments and in oblique and spiral fractures of the long bones, where 
reduction is impossible, operative intervention is justified. Many of the 
deformities, pseudo- arthroses, loss of function, and disability for work 
following fractures will thus be avoided. The unsightly deformities 
which so seriously mar the proper contour of the parts and predispose to 
refracture, excessive callus, and loss of function will be prevented. 

Fractures complicated by severe injury to adjacent organs demand 
operation. Under this heading may be included fractures in which pres- 
sure is brought to bear on neighboring viscera, nerves, and blood-vessels, 
fractures associated with dislocations, and articular fractures. The 
direct results of improper approximation of fragments are exuberant 
callus, non-union and mal-union. Nerves blood-vessels, and tendons 
are liable to be involved in this excessive attempt of nature to repair the 
loss of bony continuity. Involvement of such structures is often seen 



OPERATIVE TREATMENT OF CLOSED FRACTURES 99 

in the neuritis, oedema, and plastic involvement of tendons and tendon 
sheaths following mal-union. When excessive callus is formed at the 
seat of fractures involving joints, impairment and at times loss of func- 
tion is the result. Excessive callus occurs from imperfect approxi- 
mation and failure of accurate retention of the fragments. 

Contra-indications to Operative Treatment of Fractures. — These may 
be grouped under four headings : ( i ) those due to the fracture ; (2) those 
dependent upon the patient's general condition; (3) those pertaining to 
the operator; and (4) those relating to the environment. 

The contra-indications to be found in the fracture itself are few. 
They are generally infection of neighboring structures, and an infected 
abrasion of the skin. The contra-indications to operation dependent 
upon the patient's general condition are cardiac, renal, arteriosclerotic, 
and pulmonic in nature. Any serious involvement of these systems calls 
for the greatest care in deciding for operative intervention. Patients 
subject to chronic alcoholism and syphilis are poor risks for opera- 
tive procedures. 

The contra-indications pertaining to the operator himself are very im- 
portant. Operations upon bone require not only the most scrupulous 
aseptic care, but a great degree of manual dexterity as well as speed. The 
greatest source of infection from operations upon closed fractures are 
infection from without carried from the skin into devitalized structures, 
prolonged handling of the tissues, bruising of the soft parts, inaccuracy 
in apposition of fragments, mal-application of the internal fixation appa- 
ratus, the presence of dead spaces filled with oozing blood, and failure of 
complete hsemostasis. Anyone attempting to perform these operations 
must have a sound aseptic technic, marked dexterity, surgical judgment, 
mechanical skill, and, above all, must produce as little traumatism to the 
soft parts as possible. Otherwise, his efforts are doomed to failure. 

The contra-indications from environment are several. One should 
perform these operations only under the very best conditions. They 
should not be done where aseptic methods are doubtful. They should 
be performed only in the best equipped aseptic operating rooms, with 
assistants trained in this special class of work, and there should be at 
hand not only the ordinary instruments used in bone surgery, but in 
addition such special instruments as may be needed to manipulate frag- 
ments into place with the smallest possible amount of damage. In addi- 
tion a proper mechanical apparatus should be at hand for extension. 

Sir Arbuthnot Lane is entitled to credit for the revival of interest in 
treatment of fractures by his insistence on the common occurrence of 
defective function after methods usual in British hospitals. His enthu- 
siasm for operative fixation after exposure of closed fracture was great, 
but many calamities occurred from less skilful men following his teach- 
ing. The European War has shown the value of immediate excision 
of soft parts and removal of foreign material in contaminated open frac- 



100 TREATISE OX FRACTURES 

tures. Military surgeons have utilized the abundant experience in 
fracture treatment obtained during that great war to perfect the non- 
operative managment of closed fractures not only of the joints but of the 
shafts of bones. 

Indications that Call for Operation. — The results desired in the 
operative treatment of all fractures are : proper reduction and approxi- 
mation of the ends of the fragments; the prevention of subsequent 
deformity; the retention of alignment of the fragments; the prevention 
of pseudo-arthrosis, non-union, mal-union and deformity; the retention 
of muscular tone and normal joint movements above and below the 
seat of fracture. 

More efficient non-operative treatment is frequently the requirement 
for success in management of a fracture rather than resort to direct 
fixation after an incision of overlying soft parts. 

Exact anatomic restoration of contour is not always needed or to be 
expected. Good function and good coaptation may frequently be obtained 
by non-operative fixation, although the X-ray plate seems to show mal- 
approximation. Radiographic evidence is often misguiding, because dis- 
tortion in bone shadows, due to optical causes, is unrecognized by 
the surgeon. 

Definite rules can scarcely be formulated by which fractures may be 
classified in operative and non-operative groups. Surgeons themselves 
as well as fractures differ in quality. There is an individuality 
about patient, injury and medical adviser which must be taken into con- 
sideration before deciding as to the better course of action. It may be 
said, however, that fractures known to be accompanied by visceral injury 
requiring radical treatment, such as may occur in pelvic, thoracic and 
cranial injuries, and those with soft tissues locked between the ends of 
large fragments of tubular bones will usually require operative exposure. 
This provides the surer surgical opportunity for repair of the damage 
to soft tissues and for fixation of the bone fragments. It is probable 
that the best time to operate upon deeply-situated fractures, like those 
of the femoral and humeral shafts, is about a week or ten days after 
the receipt of injury. Two or three days is perhaps not too early to 
attack superficial fractures like those of patella, olecranon, mandible, fibula 
and tibia. When blood-vessels, nerves, brain, or abdominal or pelvic 
viscera have sustained damage, and when injurious pressure is being 
exerted by muscular contraction or original displacement of the broken 
bone, operative attack must take place immediately. 

The operation may consist of simple replacement of the fragments 
and fixation by interlocking the irregular surfaces, or reduction may be 
obtainable only after manipulations of a complicated character and effi- 
cient fixation be secured by mechanical aids. In the latter case, impaction 
of one main fragment into the other, or into its medullary canal, may 
be sufficient. Stitching the soft structures around the break with absorb- 



OPERATIVE TREATMENT OF CLOSED FRACTURES 



101 



able materials, or fastening the fragments together by sutures passed 
through the bone, may be wise. These sutures for bone may be absorb- 
able or be made of metal. If of metal they may be removed later or 
allowed to remain indefinitely. The manner of inserting sutures in bone 
vary. The essential condition is that the wire or tendon or fascia used 
should be so placed as to act mechanically to prevent recurrence of the 
displacement of the fragments. Instead of sutures of absorbable or non- 
absorbable materials metal plates may be used. 

Many conditions prevent the accurate adjustment of the fragments in 
fracture of the long bones. They may not only prevent reduction, but 
are often the cause of delayed union, neuritis, oedema, paralysis, muscular 
atrophy, loss of function, and at times absolute incapacity. 
The most frequent obstacles to the complete reduction of 
the fragments and their permanent retention are : muscu- 
lar spasm; the interposition of soft parts, as muscles, 
tendons, nerves, blood-vessels and fascia ; infiltration of 
the surrounding tissues; the piercing of adjacent muscles 
and fascia by the sharp ends of the fragments ; the inter- 
locking of fragments caused by the primary violence; 
the shortening due to __^^ 




the overriding of the 
fragments; rotation of 
a detached fragment ; 
the difficulty of pre- 
serving the anatomical 
apposition until some 
form of external fixed B 



A 



Fig. 560. — Showing 
method of holding 
fracture of long bone 
in apposition by im- 
pacting one frag- 

SS'r TralZnt^ dressing has been 

(Warbasse's Surgical „^^i* A 
Treatment, W. B. applied. 
Saunders Co.) 




F1G.56&. — Wiring broken bone. A, Wrong way; 
B, right way. (Warbasse's Surgical Treat- 
MuSCUlar Spasm, 111- ment - w - B - Saunders Co.) 

filtration of the soft parts, and interlocking of the fragments may 
be overcome by general anaesthesia, manipulation, and traction. Re- 
peated gentle massage will frequently lessen greatly the spasm and 
infiltration. The interposition of the soft parts between the fragments 
may be removed by careful manipulation and dissection. One 
should be extremely careful not to leave any of the soft parts between 
fragments, as there may result non-union and actual pseudarthrosis. 
The shortening due to overriding of the fragments may at times be 
difficult to overcome. In .recent fractures it can be overcome usually by 
traction and countertraction properly applied, under anaesthesia, or by 
continuous traction continued for several days and accompanied by gentle 
massage, or by tenotomy. 

In cases of several weeks' or months' standing, mechanical methods 
necessary for the correction of the overriding, unless carefully applied 
and adjusted, may cause marked injury to the soft parts at their points 



102 



TREATISE OX FRACTURES 



of application. The traction and countertraction are to be made after 
exposure of the fracture by the incision. Manual traction is generally 
inadequate. There are various forms of traction apparatus in use. The 
compound pulley with clove hitch or Levis plate, is sufficient ; and special 
tables are made. Accurate adjustment of the fractured ends requires, 
in addition to traction and countertraction, some form of clamp or 
forceps. The most feasible are those devised by Lane, Sherman, Lowman, 




Fig. 57a. — Circular wiring of broken bone. (Warbasse's Surgical Treatment, W. B. 

Saunders Co.) 

and Lambotte. Various forms of levers are also necessary in getting 
accurate adjustment. 

Classification of Cases Designated for Operative Treatment. — The 
Committee on the Treatment of Fractures of the British Medical Asso- 
ciation adopted in 19 12 the following classification in their compilation of 
statistics for their report. It is as follows : 

( 1 ) Those cases in which operation is 
decided upon at once and is performed as soon 
as possible (Class A). 

(2) Those cases in which operation is 
performed on account of failure to obtain 
and maintain accurate apposition by means of 
external mechanical appliances (Class B). 

(3) Those cases in which operation is 
performed for non-union, for deficient union, 
or for faulty union, whether in progress or 
complete (Class C). 

In addition to these classes there are those 
cases of fracture which are treated by non- 
operative methods, but in which there are sub- 
fig. 576'— wire passed through bone sidiary operations required. These opera- 

and twisted to hold fracture. (War- ,••,<-, 

basse's Surgical Treatment, W. B. tlOnS COnSlSt Ot tenotomies, Osteotomies, eXCl- 
Saunders Co.) • r •■ • , i r n .• 

sion of joints, removal of callus or projecting 
fragments, freeing of nerves. These cases cannot be classified with 
the above. 

Time of Operation. — Class A. — In certain fractures in which it is 
known from experience that proper reduction and retention are seldom 
obtained by non-operative means, it is advisable after preliminary radio- 
graphic examination to operate immediately ; provided the patient can be 
assured of an aseptic procedure, is free from grave organic disease, and 
has had no appreciable shock at the time of the accident, or, if so, has 




OPERATIVE TREATMENT OF CLOSED FRACTURES 



103 



recovered. Spiral and oblique fractures of the tibia, supracondylar frac- 
tures of the femur, fractures of the shaft of the femur at the junction 
of the upper and middle thirds, fractures of the olecranon, patella, calca- 
neum, with marked separation of the fragments, are quite frequently 
injuries of this character. A good index of the amount of shock present 
is the pulse, blood-pressure, and temperature. By immediate operation 
reduction of the fragments can be more readily accomplished, blood clots 
evacuated, infiltration of the soft parts, the formation of fibrous tissue 
between the fractured ends, and recurrent pain from muscular spasm 
avoided, and accurate approximation of the fragments accomplished 
without the necessity of resection with consequent shortening. Union 
will probablv result by primary healing. If, however, the patient has 




58.— Th 



illustrates the control of the leg in plating fractures, or applying 
gypsum encasement, using Dr. Hawley's table. 



not been seen for several days after the accident, or if the resulting shock 
or other circumstances prohibited immediate interference, the best results 
are probably accomplished by not operating until about the sixth or seventh 
day. This allows the circulation to be reestablished, the infiltration to dis- 
appear, and the tissues to regain tone, so that the increased traumatism 
of the operation and possible infection may be readily combated by the 
forces of nature. In this way the risk of infection is reduced to 
a minimum. 

Class B. — The performance of direct fixation by incision on fractures 
in which there has been failure to obtain and maintain accurate apposition 
by external mechanical appliances should depend upon several factors. 
In these fractures there are certain types in which a fair functional but 
a poor anatomical result is obtainable without operation. Examples are 
occasional oblique fractures of the tibia, fractures of the clavicle, of the 
surgical neck of the humerus, of the shaft of the femur, and of the shaft 



104 



TEEATISE OX FBACTUBES 



of the radius and ulna combined or separate. In these injuries operation 
should be performed when by repeated radiographic examination it is 
shown that the anatomical adjustment of the fragments is so poor that 
bad functional results with possible incapacity for work are bound 
to follow. 

Class C. — In non-union, deficient union, or faulty union the time of 
operation is dependent upon several factors. The patient's general health 




Fig. 59-— Flexion and abduction of the thigh in subtrochanteric fractures of the femur 

with or without counter-pressure on the upper fragment. Useful in applying gypsum case 

or reducing fragments. 




Fig. 



60. — Patient with the legs in extreme abduction, the Whitman position for the treat- 
ment of fracture of the neck of the femur. Hawlev table. 



should be improved and local efforts made to promote union in cases of 
non-union or deficient union. Very often sufficient time has not been 
allowed for firm union to be complete. Delay in firm union may be due 
to some general disease: in such cases the condition should be corrected. 
After all efforts have failed, operation should be performed. In faulty 
union operation maybe performed any time, although it is advisable not to 
delay too long on account of the secondary shortening of the muscles and 
the readjustment of neighboring joints and bones to the new lines of 



OPERATIVE TREATMENT OF CLOSED FRACTURES 105 

support which gradually develop. When bone-grafting is to be employed, 
because loss of substance has, in open infected fractures, given rise 
to non-union, it is wise to delay operation for about five or six months. 
This delay permits subsidence of the activity of the infecting organisms, 
which imperil often the success of bone transplantations. This caution is 
particularly to be observed in gunshot fractures of the mandible. 

A fracture table with appliances for obtaining traction is a great help 
when one proceeds to reduce the fracture, and maintain immobilization 
during operation ; also while the external gypsum case is being applied. 
Such tables are expensive and only available in hospitals, as a rule. Com- 
pound pulleys or manual traction and countertraction will usually suffice. 

Technic of Operation in Closed Fractures. — There are many methods 



... 


Li 






TT |j j 5 






■ ' *' l <f 






t .!■.. 





Fig. 6i. — Support and traction of the left arm with countertraction by a wide sling around 
the body. This position is used for operations on the humerus. Hawley table. 

of procedure in use for the reduction and anatomic approximation of frag- 
ments. The technic of exposing the fractured ends of the bones is prac- 
tically the same no matter what form of internal fixation is used. The 
technic may be divided into the following stages : preparatory treatment ; 
reduction and approximation without internal fixation; reduction and 
approximation with internal fixation. 

The preparatory treatment consists in a thorough general physical 
examination to detect, and the adoption of means to cure or modify, 
any pulmonic, cardiac, arteriosclerotic, or renal lesions, and the giving 
of a cleansing enema, if an early operation is determined upon. When 
the time has been selected, the patient should be given a cathartic. The 
local treatment consists in shaving the entire extremity, or the region of 
the fracture, followed by a thorough cleansing of the part with green 
soap, sterile water, and yo per cent, alcohol the day before operation; 
the day of operation cleansing with benzine and painting with tincture of 



106 



TREATISE OX FRACTURES 



iodine. There are many equally good methods for sterilizing a wide 
area of surface. The point is that it must be thorough. 

The operation should be performed under general anaesthesia. The 
use of the tourniquet or Esmarch bandage is not advisable, though its 
advantages might be considerable during the operation by giving a 
bloodless field. The post-operative bleeding usual after its use is unde- 
sirable, and is liable to promote wound infection. A large incision should 
be used and all bleeding controlled as it arises. The incision should be 
sufficiently large to permit thorough inspection of the fracture ends and 
protrusion of the fragments if deemed necessary. A line of approach 
to the seat of fracture should be selected which will not injure important 
structures. The muscles should be separated in their intermuscular 
planes, when possible, and if not, in a direction parallel to the course of 
their fibres; nerves and blood-vessels should be carefully avoided. The 



yr± 




Fig. 62. — Traction with pulleys and Levis's plate during 
operative fixation of old femoral fracture. 



periosteum should not be stripped away from the bone, if it can be 
avoided, and loose fragments generally should not be removed ; all bleed- 
ing should be controlled, and blood clots removed by gauze sponges; 
intervening structures should be carefully disengaged from the rough 
ends of fragments and placed in their normal relations, torn structures 
should be sutured with catgut, if deemed necessary. 

The surgeon's hands should be carefully sterilized and covered with 
sterile rubber gloves. If practicable, his fingers should be kept out of 
the wound ; the sharp fragments of bone are liable to make punctures in 
the gloves. This mishap may give rise to infection. Suitable bone- 
holding forceps, clamps, levers, and other instruments, strong and with 
long handles, add greatly to the safety from post-operative sepsis. 

Repair Without Internal Fixation. — It may be found feasible 
after reduction to maintain approximation without any means of internal 
fixation. Such cases are very few unless there is marked separation of 
the fractured ends or a parallel bone for partial support. If the operation 
is performed shortly after injury, it may then be found possible, by 
moderate manipulation, or by angulation of the fragments out of the 



OPERATIVE TREATMENT OF CLOSED FRACTURES 



107 




wound, to bring the fractured ends in apposition and lock them together 
without the use of additional means of support. Great care must be 
taken, however, to maintain the corrected position of the parts 
until the external splint is applied. 

Repair with Internal Fixation. — While, in a consid- 
erable number of operative cases, entirely satisfactory reten- 
tion may be maintained without the use of internal means of 
fixation, the majority of cases require it. Various mechanical 
appliances for fixation have been used for holding the frag- 
ments in apposition. They may be divided into six classes : 
absorbable sutures of catgut or kangaroo tendon ; nonabsorb- 
able sutures, as thread, silver and other kinds of wire (Fig. 
63) ; bone or metallic ferrules, ivory, bone or metallic plugs 
and pins, and ivory, bone or metallic nails and screws ; circu- 
lar constriction with wire or Parham metallic bands ; intra- 
medullary bone plugs ; clamps extending from the outside to 
the fragments like those devised by Parkhill ; specially de- 
signed plates and screws. 

The plates of Lane are probably most frequently used for 
fixation in nearly all varieties of fracture calling for oper- 
ative treatment (Fig. 73ft). Exceptions are fractures of the 
olecranon and patella, where probably the best results are FlG 
obtained by either absorbable or non-absorbable sutures ap- *?£ ^ t J W q { 
plied to the tendinous expansions and ligaments near the seat alu Si n £ws po ~ 





X 





" -'^ 




Fig. 64a.— Low fracture of surgical neck of right humerus. Upper end of lower fragment 

is pulled upward by deltoid muscle. 
Fig. 64b. — Application of Lane plate in low fracture of surgical neck of right humerus. (See 

Fig. 64a.) 



of fracture; certain forms of articular fracture in which the best means 
of approximation are specially designed screws or nails like those designed 
by Lambotte, Codivilla, and Roberts, which answer well. 



108 



TREATISE OX FKACTUKES 




Fig. 65. — Oblique fracture of femur treated with Parham band.. 
(Courtesy Surgery, Gynecology and Obstetrics.) 




Fig. 66. — Parham and Martin's band and instrument for tight- 
ening band around oblique fracture. (Courtesy Surgery, Gyne- 
cology and Obstetrics.) 



ZZE 




Fig. 67. — Intra-meduilary bone-graft in shatt canal used bv Mag- 
nusson after tapping the hole for screw. (Courtesy Surgery! Gyne- 
cology and Obstetrics.) 




Fig. 68. — Puth's method of using band and plate. 



The technic perfected 
by Lane should be care- 
fully followed in the 
main. The parts should 
be thoroughly prepared. 
A large, free incision 
should be made with care, 
to avoid important nerves 
and vessels. Sterile cloths 
are placed over the parts 
and attached to the edges 
of the wound by clips. 
This precaution is taken 
to prevent introduction of 
organisms from the skin 
into the wound. Bleeding 
is thoroughly controlled 
by the use of long-handled 
forceps of sufficient 
strength to thoroughly 
occlude the blood-vessels 
without the necessity of a 
ligature. All instruments 
used by Lane have long 
handles so that the oper- 
ator's hands shall not be 
placed in the wound. 
Manipulations of the 
bones are carried on by 
means of levers and 
clamps. After the ends 
of the bones have been 
freely exposed, the wound 
is enlarged sufficiently to 
expose the entire length of 
fracture and allow of a 
sufficiently long plate to 
be applied to secure im- 
mobilization of the frag- 
ments. Very little force is 
necessary to bring the 
fragments into apposition. 
The ends of the fragments 
are seized near the seat of 
fracture with powerful 



OPEEATIVE TREATMENT OF CLOSED FRACTURES 



109 




Fig. 696. 







/ 




Fig. 69c. 



Fig. 6gd. 



Fig. 69a. — Fracture of internal condyle of humerus. Fig. 69b. Anteroposterior view show- 
ing marked displacement of fragment by projection upward of olecranon of ulna. 
Figs. 69c and 6gd show fair approximation of fragments by screw and wire loop. Screw 
has broken. Final result very good. Screw not removed. Lateral view. 

forceps or clamps, and by means of traction or by protruding the 
fragments through the wound the ends may be coapted or locked. 
During the attempts at replacing the fragments, traction and counter- 
traction may be made by an assistant or by a specially adapted median- 



110 



TREATISE OX FRACTURES 




° S 

T5 O 



Dfx, 




OPERATIVE TEEATMENT OF CLOSED FEACTUEES 111 



Fig. "jia. 



Fig. 7 ib. 



Fig. 71c. 



^ 



Figs. 71a, b, c. — Result obtained by operation in case of fracture of shafts 
of radius and ulna. (See Fig. 70.) 



;.-a\\\\\- -\.-i 



, r . : .. 




Fig. 72. — Lane's bone lever for lifting ends of fragments out of wound. 







FULL SIZE 
Fig. 73a. — Lane's bone-holding forceps, 12K inches long, with serrated jaw. 




Fig. 736. — Lane's bone plate. 

ical apparatus. The fragments should be brought to their normal 
position, and normal alignment of the bone should be obtained before 
the plate is applied. An improper fixation of the plate is often the cause 
of poor position of the fragments, separation of screws, fracture of the 
plate, and infection. On no account should the plate be applied until the 



112 



TREATISE OX FRACTURES 




Fig. 74. — Sub-trochanteric fracture of left femur. Impossible 
to maintain reduction of fragments by non-operative meas- 
ures. Shows application of Lane plate, perfect anatomical 
apposition of fragments and fairly firm union six weeks after 
operation. Functional result perfect. 



fragments occupy the same 
relative position that they 
did before the fracture oc- 
curred. The plate should 
be held to the bone by a spe- 
cial clamp and one of the 
screw holes made and the 
screw introduced. A mis- 
take commonly made is in 
the use of too short a plate 
or in making screw holes 
too large in diameter. It is 
not usually necessary to 
suture the soft parts about 
the seat of fracture. Lane 
advises suturing the fascia 
lata in fracture of the 
femur. The skin wound 
may be closed with any 
form of suture or with 
Michel's skin clamps. 
Whenever possible, plates 




Fig. 75 A. — Lowman's bone clamp for adjusting plate. 
B. — Pierce's bone screw holder and screw driver. 
C — Sherman's metal-workers tap screws. 

D— Dr. H. C. Masland's instrument for holding and adjusting fragments prior to applying plate 

for fixation. 



OPERATIVE TREATMENT OP CLOSED FRACTURES 



113 



' 



y 




3 3 



ill 

* 3 o 

3 3 



O 

rt> o 





114 TREATISE OX FRACTURES 

Fig. 78. Fig. 79. 





Figs. 78 and 79. 



-Transverse fracture of shaft of femur. Application of plate, 
and anatomical results. 



Perfect functional 



should be well covered with muscles and should not be superficially 
placed. The parts should be held securely and carefully until some 
form of external dressing is applied. The best method of external 
dressing is a plaster-of-Paris encasement which should be split down each 
side immediately after application, so that the wound may be inspected, 
if necessary, and massage and passive motion given. 



OPERATIVE TREATMENT OF CLOSED FRACTURES 115 



Fig. So. 



Fig. 8i. 




w 



Fig. 80. — Oblique fracture of shaft of left femur; overlapping of fragments. 
Fig. 8 i. — Oblique fracture of shaft of left femur; application of plate. 



Fig. 82a. 



Fig. 826. 




tffi^ 



IT 



^^p 



Fig. 82a. — Photograph taken at the end of eight weeks after operation. Note absence of shortening 

and perfect alignment. 
Fig. 826. — Front view of same patient as shown in Fig. 82a taken at same time. 



m 



m 



116 



TREATISE OX FEACTUEE! 

Fig. 83. 




FiGS. 83 and 84. — Separation of lower epiphysis of femur. Difficult j 
fracture. Apposition secured by means of silver-w 



Fig. 85. 



Fig. 8( 




OPEEATIYE TREATMENT OF CLOSED FRACTURES 117 

Fig. St. Fig. 88 





Figs. 87 and 88. — Application of Lane plate and screws followed by 
moderate necrosis of ends of fragments. (See Figs. 85 and 86.) 



Fig. 89. 



Fig. 90. 





Figs. 89 and 90. — Photographs showing final results. No shortening, good function. (See 

preceding figures.) 



118 



TREATISE OX FRACTURES 

Fig. gia- Fig. 91&. 









£Hl 







Fig. 92. 



Fig. 93. 



Fig. 94. 



Figs. 910-94-. — Dislocation and fracture of humerus at anatomical neck. Reduction of dislocation 
by traction with two tenacula and leverage with curved instrument. Fixation with rectangular bone 
peg from tibia driven through tunnel bored in both fragments. Lower figures show mobility of 
left shoulder-joint and absence of deformity. (Courtesy of the operator, Dr. Simon J. Walsh. ) 



OPERATIVE TEEATMENT OF CLOSED FEACTUEES 119 

Fig. 95. Fig. 96. 







S* 



Fig. 97. Fig. 98. 

Figs. 95 and 96. — Oblique fractures of shafts of tibia and fibula. Overriding 

of fragments and shortening. 

Figs. 97 and 98. — Application of Lane plate and screws to tibia. Perfect 

anatomical apposition of fragments of tibia. (See Figs. 95 and 96.) 



120 



TEEATISE OX FKACTUKES 

Fig. 99. 





Figs. 99 and 100. — Final result in fracture of tibia -and fibula after application of Lane 
plate and screws. No shortening, perfect anatomical and functional results. (See preceding 

figures.) 



Fig. 101. 



Fig. 102. 





Figs. 10 i and 102. — Open oblique fractures of tibia and fibula. Fireman had leg caught 

in truck. 



OPEBATIVE TREATMENT OF CLOSED FRACTURES 121 

Class B. — Operations performed on account of failure to obtain and 
maintain accurate apposition by means of external mechanical appliances 
are now to be considered. Failure to obtain and maintain accurate 
apposition of the fragments may be due to interposition of soft parts, 
to the nature of the fracture itself, to muscular action, or to faulty 
methods of immobilization. These cases are best treated by a primary 
period of extension for several days in order to overcome the muscular 
contraction. The only difficulty in operations of this class is that of 
proper approximation without resection of the ends of the fragments. 
This usually may be overcome by manipulation of the fragments or by 
angulating them out of the wound and after locking them forcing them 
into the wound while extension is made. The ends of the fragments 
should be carefully freed of portions of muscular tissue, granulations, 
and callus. The technic otherwise does not vary from that of operations 
performed immediately after the injury. 

Class C. — Those cases in which operation is performed for non-union, 
or faulty union, are more difficult to treat on account of the presence of 
secondary shortening and overriding of the fragments, muscular con- 
tractures, the greater time required for the operation, and the necessity 
of reconstructive procedure on the ends of the fragments. Martin has 
shown that there is a rapid and at times a faint fall of blood-pressure 
with resulting shock from traction alone. This is particularly so in 
operations for delayed or faulty union of the femur in which traction is 
necessary. Careful observation of the pulse and blood-pressure should 
be made in these cases, while forcible traction is being used. 

Constitutional diseases play a small part in the prevention of union, 
though they may be important factors in delayed union. Examination 
in non-union cases not infrequently shows the fractured ends to be 
separated and the intervening space filled by muscle or fibrous tissue. 
The ends of the bone generally override and are smooth, and a condition 
of pseudo-arthrosis may be present. Sometimes, how r ever, there is found 
absorption, or atrophy, with sclerosis of bone ends. The later condition 
occurs when primarily there has been loss of bone from gunshot or 
machinery injury or secondarily from infective necrosis. Traumatic 
laceration of the nutrient artery may be a cause of the necrosis. The 
technic of operation varies somewhat from that used in recent fracture 
cases. An extensive armamentarium is necessary to properly operate, 
and the use of efficient tools is the chief means of lessening the resulting 
possible infection by providing for a short operation with little trauma- 
tism. Here again one should guard against shock from prolonged 
traction. The pulse and blood-pressure should be carefully watched. 
All fragments of callus, and all muscular, fascial and fibrous tissue should 
be removed from between the fragments. These objects may be the cause 
of failure of union, and their removal with proper fixation of the frag- 
ments will do much to ensure union. In old standing cases of ununited 



122 



TREATISE OS FKACTW 




Note m „ 3 de ^ e Sfer m hTf„H° b ' a i?fl5 f '« «*«* 



rat aa^sg SjsafitBstK 



Fig. 105. 




Fig. 106. 




Fr GS. 105 ANT) 106.— 



functional results. ° ICW - Good anatomical and perfect 



OPEEATIYE TREATMENT OF CLOSED FRACTUBES 



123 



fracture and mal-union (Figs. 101-109), it is necessary to resect the 
end of the fragments beyond the sclerosed area until the bone-marrow 
may be seen. This is important because the wished- for callus to unite the 
bone is furnished by the organic cells in the marrow canal and the Haver- 
sian system of the broken bone. A bone-graft from rib, tibia or ilium 
may be necessary to bridge the gap, left by cutting away ends, in order to 
obtain contact with well-nourished living bone at both ends of the space 
between the sawed-off fragments. Necrotic pieces must be removed 
and the activity of infectious conditions given weeks to subside in non- 
union where bone-grafting is expected to give a good solid repair. In 
some of these cases it is necessary to remove large masses of exuberant 



Fig. 101 



Fig. 108. 











Figs. 107 and 108. — Closed fracture of shaft of the tibia, followed by an acute suppurative 

osteomyelitis. Shaft of tibia removed. Upper portion of tibia has regenerated. Lower 

portion as shown between two arrows consists of half of first metatarsal bone used as a 

graft made by Dr. F. T. Stewart. No union between portions of new bone. 

callus in order to approximate the ends of the fragments. Plating is not 
always necessary. There is no doubt that the presence of a foreign body 
the size of a metal plate often retards osteogenesis, and in many cases 
in which plates are used the resulting delayed union is due to this fact. 
Of great importance in the operative treatment of fractures is a 
careful retention of the coaptation until some form of external splinting is 
applied. Change in the line of the distal fragments will often produce 
such strain upon some of the screws as to pull them out entirely and in 
some cases to even fracture the plate. The vanadium plate and screws, 
devised by Sherman, overcome, to a considerable extent, these drawbacks 
to the use of plates. The best form of external splinting is a carefully 
applied casing of plaster-of -Paris. This should be cut down each side so 
that massage and passive motion may be instituted within ten davs. At 



124 



TREATISE OX FRACTURES 



the end of a few weeks a patient with a fractured tibia or femur may be 
allowed up on crutches, if the external casing gives proper support, and 
weight-bearing on bone is prevented. 

Dr. F. H. Albee has had valuable results from the use of bone-grafts in 
the operative treatment of recent fractures in which reduction cannot be 
obtained without exposure of the ends of the fragments. He uses a long 
strip of bone cut from the patient's tibia, and inserts it in a groove cut 




Fig. 109. — Photographs of Figs. 107 and 108 showing shortening, deformity, and muscular atrophy. 



in the ends of the fragments so as to act as an autogenous splint. He has 
devised special instruments for removing the transplant or graft from 
the normal tibia and for cutting the groove in the fractured bone, which 
make his procedure a rapid, neat, and satisfactory one (Fig. new). He 
also has special instruments for cutting the bone graft into pegs or dowels 
and for boring holes in the bone to be repaired for the insertion of 
kangaroo tendon sutures or, in certain cases, the bone pegs. The parallel 
or twin saws, the drills, and the instruments for making the nails or dowels 
are driven by an electric current. The Albee operation is particularly 



OPERATIVE TREATMENT OF CLOSED FRACTURES 



125 



valuable in ununited fractures, because it not only holds the resected 
ends of the fragments in correct alignment but furnishes osteogenetic cells 
which aid greatly in the development of ossific union. His method may 
be used without his complicated and extensive tools, but their use lessens 

Fig. noa. 




Fig. nob. 




Figs, noa and iio&. — (a) Albee's electric twin saw used in removing transplant from 
tibia and for cutting groove in the fractured bone. \b) Albee dowel cutter. 

the time of operation and makes the result a neater looking one. Chisels, 
ordinary drills, osteotomes, and saws of various kinds will accomplish 
the same result in the hands of any surgeon with usual manipulative skill. 
Dr. H. C. Masland, of Philadelphia, has recently devised a saw which 




Fig. in. — The Masland saw. 



is exceedingly convenient in these bone operations (Fig. in). It is less 
cumbersome than the Albee saw. 

The inlay graft (Fig. 112), as he calls it, is inserted after the fracture 
has been exposed by a free incision and the ends of the fragments cleared 
from surrounding soft parts. Excision of the ends, if necessary, other- 
wise simple manipulation with moulding, is used to overcome deformity. 



126 



TEEATISE OX FKACTURES 



— b 



When the freshened ends of an ununited fracture or the bare ends of a 
recent fracture are in proper apposition, a gutter is made with the twin 
saws one-third to one-half inch in width. If the fracture is an ununited 
one, this gutter should run well beyond the fracture ends. It is wise to 
previously saw off atrophic and sclerosed ends. In the tibia, for example, 
the parallel cuts should extend into one fragment for a distance of about 
five inches; into the other about two and a half inches. The strips of 
bone between the parallel saw cuts, which go down to the medullary 
canal, are removed by dividing the bone at the 
ends with a small osteotome or circular motor 
saw. The short strip is laid aside and the long 
one returned into the gutter so as to cross the 
break between the two> fragments of bone, making 
a splice or inlaid splint. Placing the bony strip 
in this position leaves a short gap between the end 
of the gutter and the end of the inlay in the frag- 
ment of bone from which the longer piece was 
taken. This unfilled portion of the channel is 
necessarily the exact length of the piece of bone 
which has been laid aside. This strip can be pushed 
into the gutter in order to reconstruct that portion. 
Such reposition is not necessary if the sur- 
geon thinks that he needs it to cut into nails or 
pegs for fastening other fragments of the same 
injury. The inlay is held in place by kangaroo 
tendon sutures, passed through holes drilled in 
the sides of the gutter, carried under the inlay, 
and the ends tied over the inlay so as to force it 
down and hold it deeply in contact with the floor 
of the gutter. Four or five of these sutures are 
sufficient. Small chips of bone, taken from re- 
sected ends or from clean fragments removed 
in preparing the ends for operation, are dis- 
tributed about the seat of fracture if there are 
vacancies to be filled by new bone. 

When an old ununited fracture is to be treated by the inlay method, 
the graft is taken from a healthy tibia of the patient. The width and 
length should be similar to the one cut out of a recent fracture to fix 
the same. Live bone pegs, or bone dowels, may be made from pieces 
taken in a similar manner. The inlay graft has for its only function the 
maintenance of apposition and alignment, and it should not be ex- 
pected to take the place of external support necessary to prevent 
accidental displacement from muscular movement or the handling of 
the patient by nurses. A gypsum dressing is applied after the soft 
parts have been sutured without drainage and appropriately dressed. 




Fig. 112. — Albee's method 
for fixation of fractures by- 
inlay bone-graft. Graft has 
been cut from upper fragment 
and a groove cut into lower 
fragment. The inlay graft is 
then placed in position as 
shown and held in place either 
by bone pegs as shown in a or 
by means of kangaroo tendon 
sutures as shown in b. 



OPERATIVE TREATMENT OF CLOSED FRACTURES 127 

Instead of using grafts with parallel sides cut with twin saws, Doctor 
Albee thinks that in some cases, particularly in fresh fractures, it is 
preferable to use a single saw and cut the transplant with converging 
sides going down to the marrow cavity. This gives a graft long and 
with wedge-shaped sides, cut down to the marrow canal. In making pegs 
of live bone Doctor Albee prefers the cortical bone taken from the lower 
third of the tibia, because it is stronger. Such pegs or dowels can be 
used for fractures of the neck of the femur and, being living tissue, are 
probably much better than the ivory or dead bone dowels or pegs used 
by other surgeons years ago. Albee does not care particularly in 



Fig. 113a. 




Fig. 113&. 




Figs. 113a and 1136. — Open ununited fractures of tibia and fibula. Note great overriding 
of fragments, with deformity and shortening. 



using bone-grafts whether the periosteum is removed or left attached 
to the graft. The value of living bone is much greater in these plastic 
reconstructions of bones than that of foreign materials. A centre of 
osteogenetic activity is provided by the insertion of the living bone from 
the patient's tissues. 

The time has probably arrived when the relative values of the blood- 
less and the blood-shedding routine treatment of fractures may be settled. 
Sir Robert Jones, of Liverpool, was of the opinion a few years ago that 
simply improvement in the customary non-operative treatment of frac- 
tures would markedly increase its percentage of good results. Campiche, 
of San Francisco, has recently expressed his belief that bloodless surgery 
will probably, in competent hands, give excellent anatomical and func- 
tional cures in 90 per cent, of cases. 



128 



TREATISE OX FRACTURES 



The British Fracture Committee concluded, in 1912, that a consider- 
able proportion of failures of operative treatment arose from infection, 
a possibility even with the best technic, and that the operative method 
required special skill, experience and equipment ; that although func- 
tional cure may be good with an indifferent anatomical result, the most 
certain way to obtain a good functional result is to secure a good anatomi- 
cal cure ; that no method not definitely promising a good anatomical result 



Fig. 114a. 



Fig. 114&. 








Figs. 114a and 114&. — Inlay bone-graft in place in tibia. Note alignment of fragments 
with absence of deformity, except shortening. Single arrows point to site from which graft 
was taken and double arrows show two views of the graft slipped down into place. (See 
Figs. 113a and 113b.) (.Courtesy of Dr. Morris Booth Miller and Dr. George G. Ross. 
Operated by Dr. Albee.) 

should be the chosen method of treatment; that the direct mortality of 
blood-shedding treatment was so small in competent hands as not to 
furnish a sufficient reason for its rejection, and that to insure its best 
result it should be adopted soon after accident. 

In 1 91 3 the American Surgical Association Fracture Committee for- 
mulated these conclusions : That practitioners not trained in surgery as 
a specialty should adopt a routine non-operative method midway between 
prolonged immobilization on the one hand and the mobilization method 
of Lucas-Championniere or the traction method of Bardenheuer on the 



OPERATIVE TREATMENT OF CLOSED FRACTURES 129 

other; and that the watchwords for this class should be anaesthesia, 
plastic splints or traction, frequent inspection, frictions, early mobility, 
and the delay in weight-bearing. That trained surgeons, restricted by 
moderate efficiency and facility, either personal or hospital, probably 
should adopt a routine of less prolonged immobilization than heretofore, 
or of traction with frictions, early light massage and mobilization for the 
usual run of fractures, and that they should restrict operative treatment 
to fractures known to be especially rebellious or found to be so after 
a few days' study. 

The Committee's answer to the question, " What should be the 
routine treatment for the skilled surgical expert with adequate facilities ? " 
was that it makes little real difference in morbidity or mortality whether 
he adopts a bloodless or a blood-letting method for obtaining a func- 
tional and an anatomical cure, provided that he personally dominates 
the situation as to reduction, fixation and after-treatment, and sets the 
time at which the patient shall resume his original occupation ; and pro- 
vided he abandons the prolonged immobilization and accompanying negli- 
gence so customary in recent years on the part of many having the care 
of fracture cases in hospital wards. 

The American Surgical Association's Fracture Committee reported 
in June, 191 5, as its belief : that in non-operative management of fractures 
there is no method or splint universally applicable nor has any given splint 
or apparatus proved its superiority; that traction methods are very fre- 
quently unskilfully employed, and with too little weight used ; that counter- 
traction is generally required, and that the gauge of the proper weight is 
the amount necessary to overcome the shortening; that plaster encase- 
ments and moulded splints are especially useful after the fracture has 
been satisfactorily reduced ; that fractures should be reduced immediately 
after injury, if it is possible to obtain and apply at that time proper 
retaining appliances; that anaesthesia should be employed, as a rule, to 
facilitate reduction and prevent pain; that neither the non-operative nor 
the operative method is to be recommended exclusively ; that the operative 
method, when adopted, should be employed early, and should, for closed 
fractures, be undertaken only by experienced surgeons, thoroughly 
equipped by training, and with proper instruments and apparatus. 



CHAPTER VI 
INCOMPLETE UNION AND MAL-UNION OF FRACTURES 

Varieties. — Defective union of the fragments of a fracture is to be 
deprecated. It means impairment in a greater or less degree of the 
patient's bone efficiency. A want of complete rigidity may cause failure 
of the entire function of a limb or merely leave a painful point of mobility, 
where no motion should be possible. A slight alteration in anatomical 
outline is not necessarily a disability. If it occur in childhood or adoles- 
cence in the shaft of a bone, it may be compensated for, or entirely dis- 
appear, during growth to adult years. Much depends, however, on the 
character and site of the mal-union, as well as the degree of anatomical 
inaccuracy of outline. Deformed union of a nasal bone may be a 
cosmetic defect of importance and functionally of marked importance 
by reason of interference with respiration. Secondary results may arise 
in children, causing mouth-breathing, imperfect dental occlusion and inter- 
ference with the shape of the features and of general health. On the other 
hand, an abnormal curve in the shaft of the femur, even of considerable 
degree in a growing child, may straighten out in succeeding years and 
leave no lameness or marked inequality in femoral symmetry. 

Mal-union of a fracture may be imperfect or vicious because con- 
solidation has occurred with abnormal position of the fragments, 
thereby changing the bone's shape; or because no rigid bond of union 
has been developed to give normal rigidity at the site of fracture. The first 
condition, or anatomical deformity, may be objectionable merely be- 
cause beauty of contour has been sacrificed, which is of minor importance 
in some regions of the skeleton; but a functional disability from change 
in bony outlines which restricts motion or other normal usefulness is, 
however, of greater moment. A joint may be choked by an irregularity 
within or near it, a limb shortened, the axes of bones altered, or the 
mechanical efficiency of the skeleton lessened, by changes in the contact 
planes of articulating surfaces or by impairment of the functional ability 
of the surrounding soft parts. The terms deformed union or mal- 
union have been used to describe these vicious deviations from satis- 
factory healing. 

Causes and Pathology. — Failure to reduce a fracture at the beginning 

of treatment may result in mal-union, non-union, or combination of both. 

This is evident from the recognized requirement of coaptation, if proper 

alignment, freedom from overriding, and absence of rotary displace- 

130 



INCOMPLETE UNION AND MAL-UXION OF FRACTURES 131 

ment are to be secured. Infrequent examination and consequent failure 
to notice and remedy deviations from proper contour, while callus is soft, 
is a pregnant cause of mal-union. In this variety of imperfect union, there- 
fore, early reduction and frequent removal of dressings in the early days 
of treatment are essentials. Similar activity and wide-awakeness are 
important qualities of the fracture surgeon, if delayed union, non-union, 
or development of true pseudarthrosis is to be recognized early enough 
to avert the undesirable occurrence or to relieve the resulting disability. 
In a word, deformed union in closed uncomplicated fractures is usually 
due to lack of knowledge of efficient treatment of the fracture or to 
neglect in applying well-known mechanical and physical principles to the 
problem of treatment. There are, of course, cases, not a few in number, 
in which intractability of the patient, complicated character of the injury 
or uncontrollable conditions render perfection in treatment impossible. 
Deformed union of various degree is more frequently seen than non-union. 

Another possible deviation from the usual process in repair of sun- 
dered bones is delay in ossification of the fibrocartilaginous tissue, the 
so-called callus, deposited between and around the fragments of bone. 
Nature uses this callus to maintain continuity and relative immobility of 
the pieces until the fibres of the apposed surfaces have become rigidly 
joined by the osteoblasts. The divergent views of pathologists as to the 
parts played by periosteum, endosteum, marrow and contents of the 
Haversian system in union of fractures need not be discussed in this 
consideration of imperfect unions. 

Delay in union may be due to some abnormal condition of the patient's 
blood and solid tissues. In such case, union occurs after a longer con- 
valescence than is experienced in similar fractures in other persons. 
The question of moment is the discovery of the cause, psychic or physical, 
mechanical or metabolic, of the delay. A query, however, also arises 
in the surgeon's mind as to when the delay has been sufficiently protracted 
to become an urgent reason for adopting the treatment proper for 
a true non-union. 

The most troublesome form of defective consolidation is absolute 
failure of the bone to reestablish its continuity and give normal skeletal 
rigidity. The bone ends may atrophy and become pointed and compact ; 
or there may be created a bursal sac between the opposing surfaces, re- 
sembling a true synovial joint cavity. The latter is the so-called false 
joint, which may be differentiated from absolute non-union. This exists 
when two wedge-shape, or pointed ends lie near together with no bond 
of union whatever or only a flail-like band of ribbon between them. 

It seems likely that the atrophic condition occurs when there is defec- 
tive metabolism of the patient, or a decided loss of bone structure, from 
comminution or necrosis, preventing contact even after reduction. Ina- 
bility to get the ends of the bone in contact because masses of muscle 



132 TEEATISE OX FRACTURES 

or tendon lie between the broken surfaces will explain many instances 
of false-joint (pseudarthrosis). The musculo-fibrous tissue prevents 
actual contact of bone ends, the osteoblastic cells are unable to cement the 
fragments together, and the resulting mobility and friction give rise to a 
bursa to lessen friction. Infected fractures, especially those due to gun- 
shot injury, are very liable to delayed or deformed union. 

Association of deformity with the failure of union would be expected 
when pseudarthrosis has developed as a result of entanglement of frag- 
ments in extensively lacerated muscles. When a fragment has been thrust 
through a buttonhole made in a muscle by its sharp end. atrophic non- 
union would be rather likely to be found, especially if the surgeon has 
failed to withdraw the perforating piece of bone from the muscle belly 
so as to bring it into contact with its fellow fragment. 

It will be seen, therefore, that imperfections in the consolidation of 
fractures may occur as delay in union, deformed union, production of 
a joint-like union, total lack of union, or a combination of these defects. 

Treatment. — In deformed union, subcutaneous refracture for the cor- 
rection of angular deformity of a shaft is comparatively easy for from 
three to six months after injury. The cross-breaking strain is readily 
applied by grasping the ends of the bones and using the viciously united 
fragments as levers. When necessary a wedge-shaped fulcrum mav be 
applied beneath the convexity of the union to localize the fracturing force. 
The operator's bent knee or a padded block is available. In long-standing 
deformity of big bones like the femur, it may be necessary to increase 
the operator's manual power by bandaging a flat board to the limb so as 
to stiffen the distal joint and thus lengthen the lever to which the power 
is to be applied. 

Occasionally simultaneous traction upon the distal portion of the limb 
may aid. Perhaps this is more valuable when the angular distortion is 
combined with overlapping. The clove hitch or the Levis traction plate 
well supplies the attachment to the limb. Radiographic examination of 
the osseous bond will give a fair idea of where and how the breaking 
strain should be applied. Driving an osteotome between the fragments 
in one or two places will weaken the connection and render the refracture 
possible with less expenditure of force. The small incision in the soft 
parts, as in correction of knock-knee and bow-leg. need not destroy the 
practically subcutaneous character of the operation. 

Osteoclasts are seldom to be used in these days of successful aseptic 
open operations. Conditions may arise, however, in which these 
machines are to be preferred. Such must be unusual. 

The last-named aids to the manual power of the skilled operator are 
more likely to be called into play when the deformity is caused by over- 
lapping or rotary displacement of the fragment ends. Such deformities, 
too. are the ones in which subcutaneous rupture may be unsatisfactory. 



INCOMPLETE UNION AND MAL-UNIOX OF FRACTURES 133 

It is in these instances that open osteotomy is most frequently to 
be selected. 

Subcutaneous correction of vicious union is available and successful 
for a long period after the fragments have been firmly united. Deform- 
ity from unreduced fracture at the lower end of the radius may be cor- 
rected thus at four to six months. Firm union of deformed fracture 
of the shaft of the femur may be ruptured subcutaneously up to six 
months. The time of successful disruption will depend upon the charac- 
ter of the displacement, the method of applying the power, and the famil- 
iarity of the surgeon with the methods. Recently the bandaging of a 
board to stiffen the knee gave one of us leverage enough to break up a 
badly united femur impossible to manage with the hands alone. The 
after-treatment is to be conducted on the same lines as are employed in 
similar accidental fractures. The surgeon will often be aided in the 
choice of method by a careful study of the causes of failure to obtain 
proper coaptation in the original bone injury. 

In delayed union, deposit of callus should be hastened by massage of 
the limb, good food, fresh air, happy surroundings, hopeful attendants, 
and congestion of the limb by continuous or interrupted use of rubber 
constriction on the proximal side of the fracture. Calcium carbonate 
grains v — x and calcium lactophosphate grains v - x in powder, three or 
four times a day, as an internal remedy, or calcium chloride may be useful. 

There is the need of due appreciation of the value of psychic as well 
as mechanical and medicinal agents in the surgery of delayed union. This 
is the reason that sometimes operative attack is too hastily undertaken 
for the treatment of delay in consolidation of fractures. 

Supplementary helps in securing callus formation in delayed union 
are massage, hot-water bathing, permitting some use of the limb, passive 
congestion with rubber constriction above the break, rubbing the ends 
together by manipulation, and injecting blood hypodermically into< the 
tissues around the fracture. 

When it is evident that the delayed union is likely to be permanent, 
treatment for non-union must be adopted. It should be remembered 
that experience seems to show that direct fixation with metal plates retards 
consolidation of fractures. Hence, former views of the time limit 
allowed for consolidation before accepting the diagnosis of non-union 
should be somewhat lengthened in recent fractures treated with 
metal plates. 

Non-union and actual false joint present great difficulties in suc- 
cessful treatment. They are fortunately rather unusual occurrences 
in uncomplicated fractures. Patients in poor health, when the fracture 
was received, persons with multiple fractures due to very serious trauma- 
tisms are more liable to deficient callus and unattained ossific consolidation 
of the bone injuries. 



134 TREATISE OX FEACTUEES 

Interposition of soft parts between the fragments, infection, insufficient 
arterial supply and wide separation of fragments or loss of considerable 
bone substance by the injury or secondary necrosis are effective in pro- 
ducing pseudarthrosis or entire absence of union in even those previously 
in vigorous health. 

Bad general condition of the patient leading to inefficient metabolic 
activity at the site of fracture may be responsible; or local malignant dis- 
ease or osteomalacia may be present. Imperfect coaptation preventing 
osseous contact, a great degree of muscular displacement and perhaps 
faulty immobilization are possible factors in the production of a mere 
fibrous union or to a false joint. Delayed union is more apt to be due 
to deterioration of vital forces: but non-union and false joints nearly 
always depend from a local cause. This is apt to be mechanical. A frac- 
ture that remains painful long after union is apparently obtained will 
usually be found on close examination to be the seat of a slight degree 
of abnormal mobility. Ununited fracture has in many instances this 
accompaniment of pain on use of the limb. 

When the treatment suitable for delayed union has been tried, or 
radiographic examination shows that diagnosis of non-union is appli- 
cable, operative treatment may be said to be demanded. This aims at 
removing the local cause and stimulating fundamental activity ; or, at 
converting the old ununited fracture into a recent one with fresh surface 
placed in contact with each other. 

The subcutaneous method is to violently bend and rotate the frag- 
ments so as to forcibly tear asunder the fibrous connections and strongly 
rub the ends together. This may be followed by tenderness, swelling 
and consolidation. The manipulation, to be thorough, requires anaes- 
thesia, and should be of a character to bend the fragments at a right 
angle, rotate and extend as much as safety to vessels and nerves will 
allow. Immobilization with rigid external support is the after-treatment. 

Aseptic precautions have made exposure of the seat of non-union so 
safe that now the surgeon rarely delays long before attacking the un- 
united fracture through a free incision. This allows more accurate 
information as to the local cause of the failure of union, and a wiser and 
more successful direct management of the condition. 

In pseudarthrosis onen operation is the only efficient treatment, and 
even in the less perfect illustrations of false joint it is often to be adopted. 
The fragments are freed from fibrous muscular tissues, the ends, often 
atrophied, sawed off. and placed in contact. If atrophied the fragment 
must be exsected at a point well above the narrowed compact portion so 
as to expose a wide surface of cancellous bone. The bare surfaces should 
be placed in contact, or a graft of bone, preferably autogenous, may be 
placed between the freshened ends. Coaptation should be obtained and 
may be maintained by an autogenous inlav graft, as suggested by Albee; 



INCOMPLETE UNION AND MAL-UNION OF FRACTURES 135 

or, bv pegs or dowels of bone, or. plates, screws, wires or catgut mats. It 
is possible that the suggestion of using fascia from the fascia lata of 
the thigh as a sheath or cuff to maintain the contact may prove valuable. 
External support by a gypsum splint or encasement is used as in acci- 
dental fractures for the maintenance of correct position of the fragments. 
This should be continued for many weeks, for hasty mobility is usually 
an error in operative surgery of ununited fractures. In fracture of one 
of the parallel bones of the forearm, it should be seen that the resected 
bone is not prevented from contact, because the one which has not been 
broken is longer. In such cases the gap between the fragments should be 
bridged by an autogenous graft from the patient's tibia, a dowel graft 
driven into the medullary canal of the two ends, or a wedge-shape graft 
driven between the fragment ends. 

It has been suggested that when repair is likely to be inactive, the 
wound might be left open and packed with sterile gauze to cause irritative 
increase of metabolic changes. The surgeon should always see that there 
is contact of considerable surfaces of cancellous bone; and look to giving 
the patient happiness, fresh air and good food. Too little attention to 
these hygienic factors is a common fault among us surgeons. A good 
judge is said to need his law tempered with justice and mercy. A frac- 
ture surgeon needs his mechanics tinctured with psychology, physiology, 
and hygiene. 

Combination of deformed union and non-union is apt to be a most 
troublesome problem for surgical repair. An elbow may be chocked, the 
forearm bones displaced by muscle at the seat of fracture and the frag- 
ments ununited and atrophied. The femur and patella may be broken, 
one of the fractures being open, the other closed, and the patient the 
subject of grave malnutrition and despondent mind. Such problems re- 
quire patience, enthusiasm, faith, skill and time to bring about the hoped- 
for convalescence. 

If an operation for non-union has failed to give the patient a firm 
union, after careful abstinence from meddlesome mobility and the judi- 
cious general and psychic treatment advocated above, the surgeon usually 
should allow a period of several months to elapse before undertaking 
another open operation. This is especially true in fractures which have 
been infected originally or after the operation for relief of the non-union. 

Infected open fractures are especially prone to deformed union, de- 
layed union and non-union. Such fractures and fractures, in which 
operative fixation has been followed by infection and failure in repair, 
need a far longer period of fixation and abstinence from operative dis- 
turbance than do those which have been given time for the previous 
infecting organisms to lose virulence (Fig. 115). 

In operating upon ununited fractures (Fig. 116), where there is a 
pseudarthrosis, it is usually wise to dissect away very thoroughly the 



136 



TEEATISE ON FEACTUKES 



false capsule and the synovial bursa between the fragments. The com- 
pact tissue at the ends of the bone constituting the false joint should be 
reamed out in order to expose the medullary cavity and the osteoblasts, 
from which new bone is expected to develop. Bone pegs cut from the 
tibia may then be inserted into the medullary cavity and external fixation 
used by means of a gypsum encasement. In the X-ray study of the 
progress toward union after operations for ununited fracture, it may 



■A 




Fig. 115. — Pseudarthrosid in fracture of the humerus of eleven years' standing. Union obtained by bone 
transplantation combined with use of Lane plate to maintain fragments in apposition. (Dean Lewis.) 



be observed that the transplant, whether a dowel or an inlay, has become 
united by bony growth at only one end. Should the condition of non- 
union persist, as shown by repeated X-ray examinations, and union take 
place at the other end of the graft, it is proper after the lapse of a few 
months to reopen the wound. An operation should then be performed to 
obtain contact between the ununited end of the graft and the fragment 
at the end of which union has not occurred. 

In non-union operations it is sometimes well to use wire or a Lane 
plate for direct fixation at the time of operation, in addition to the 



INCOMPLETE UNION AND MAL-UNION OF FRACTURES 137 



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138 TEEATISE OX FBACTTTRES 

steadying of the grafted region with the external plaster-of-Paris encase- 
ment. In difficult cases much stress must be laid upon the necessity 
for a very prolonged fixation in the gypsum case. This is because many 
patients fail to get union on account of the fact that they desire to hurry 
up motion in the neighboring joints. Prolonged fixation of the seat of 
operation for many months is often essential for obtaining union. Early 
removal of the cast, or attempts at motion at the adjacent joints, may 
lead to absolute failure of the grafting operation. 



CHAPTER VII 

FRACTURES OF THE CRANIUM 

General Considerations. — Cranial fractures differ from those of other 
regions in not being displaced by muscular action and in not needing 
retentive apparatus to maintain coaptation of fragments. In many frac- 
tures of the cranium the bone injury is of secondary importance and the 
treatment must be directed more to the associated injury of the cranial 
contents than to the fracture itself. Fractures of the cranium may be 
limited entirely to the locality of impact of the fracturing force without 
injury to the cranial contents. On the other hand, there may be frac- 
tures in which there is little if any injury at the site of the fracturing 
force, but there may be extensive damage done to the brain and 
its membranes. 

The contents of the three fossae at the base of the brain may be 
enumerated as follows. 

Anterior cerebral fossa : frontal lobes, olfactory nerves. 

Middle cerebral fossa : temporosphenoidal lobes ; cavernous sinuses ; 
internal carotid arteries ; optic nerves ; motor oculi nerves ; trochlear 
nerves ; trigeminal nerves ; abducent nerves. 

Posterior cerebral fossa: cerebellum; occipital lobes; lateral sinuses; 
seventh, eighth, ninth, tenth, eleventh and twelfth nerves. 

Skull — Anatomy. — The skull is the bony covering of the brain and 
the container of the mouth and the organs of hearing, seeing, and smelling. 
It is divided into the bones of the cranium and the bones of the face 
(Fig. 117). The cranial bones are the frontal, the parietal, the tem- 
poral, the occipital, the sphenoid, and the ethmoid. The bones of the 
face are two superior maxillae, two malar, two nasal, two palate, two 
lachrymal, two inferior turbinated, one vomer, and one mandible or 
inferior maxilla. It should be recollected that the walls of the cranium 
consist of two tables separated by a greater or less amount of soft, vascu- 
lar, cancellated, bony structure called the diploe. The inner table is nearly 
always more extensively broken than the outer, because the fracturing 
force is, as a rule, applied from without, inwards. The fracture at the 
point of exit of a perforating bullet reverses this condition. The thinnest 
parts of the cranial wall are in the orbital, ethmoidal, squamous and in- 
ferior occipital regions. The frontal region, after the age of infancy, 
contains large cavities, the frontal sinuses of the nose, between the two 
tables of bone. 

The cranium encloses the brain, its membranes and blood-vessels, 
and may be divided into the vault and the base. 

The principal landmarks of the cranium (Fig. 120) may be briefly 

139 



140 



TEEATISE OX FRACTURES 



enumerated : Sutures: Frontal suture, between the two frontal bones, 
obliterated early in life; sagittal suture, separating the two parietal bones; 
coronal suture, separating the parietal and the frontal bones ; the lamb- 
doid suture, separating the parietal and the occipital bones. The glabella, 
the flat surface above the root of the nose; the bregma, the junction of 
the coronal and sagittal sutures which is the position of the anterior 
fontanelle in infancy. The lambda is the junction of the sagittal and 
lambdoid sutures, and is the position of the posterior fontanelle in infancy. 
The pterion, the junction of the anterior inferior angle of the parietal, 



Orbital foramen 

Exter. angular process 
Lesser wing of sphenoid 

Optic foramen 

Ethmoid 

Lachrymal groove 

Middle turbinate 

Inferior turbinate 



Mental foramen 




Nasal bone 

Frontal 

Great 'ning of sphenoid 

Malar 

Superior maxillary 

Infra-orbital foramen 

Nasal septum 

Anterior nasal spine 



Styloid process 



Fig. 117. — Front view of skull (Piersol). 



the frontal, the temporal and the greater wing of the sphenoid bone ; its 
location is almost one and a half inches behind the external angular 
process of the frontal bone and about the same distance above the zygoma. 
The inion, or external occipital protuberance, may be palpated in the 
median line posteriorly at the junction of the head and neck. This point 
marks the position of the torcular Herophili, or the junction of the 
superior longitudinal, the straight, the occipital, and the two lat- 
eral sinuses. 

The course of the frontal and sagittal sutures corresponds to a line 
drawn from the root of the nose (glabella) backward in the median 
line to the external occipital protuberance (inion), and marks the posi- 
tion of the superior longitudinal sinus and the longitudinal fissure of 
the cerebrum. 

The mastoid process can be readily palpated behind the ear. About 



FBACTURES OF THE CRANIUM 



141 



SUPERIOR FRONTAL 
FISSURE 
i 2 



FISSURE OF^ROLANDO 



CALLOSO MAR6INAL. 
,'4 F I 5 S U R Z 




FISSURE OF 
SYLVI US 

Fig. 118. — Diagram of chief convolutions and fissures of brain (Roberts). 




Fig. 119. — Diagram of exterior of cranium and its relation to intracranial 
structures (Roberts). 

half an inch above and three-quarters of an inch posterior to the tip of 
the mastoid process is the junction of the lambdoid and squamous 
sutures, the asterion. The position of the horizontal portion of the lateral 
sinus is represented by a line drawn from the external occipital protuber- 
ance to a point one inch above the external auditory meatus. The course 



142 



TREATISE ON FRACTURES 



of the sigmoid of the lateral sinus may be represented by a line drawn 
from the termination of the horizontal portion of the lateral sinus to 
the top of the mastoid process. The middle meningeal artery, a branch of 
the internal maxillary artery, enters the cranial cavity through the fora- 
men spinosum. It occupies the groove in the greater wing of the sphenoid 
bone and divides into the anterior and the posterior branches. The 
anterior branch crosses the great wing of the sphenoid and enters the 
groove in the anterior inferior angle of the parietal bone. During a 



Stephanion 
Inferior stephanion 



Bregma Biauricular line 



Obelion 




Malar point 
Mveolar point — O'i 



Mental point 



Gonion 

Fig. 120. — Lateral view of skull (Piersol). 



part of its course this groove is converted into a canal. The anterior 
branch continues through this canal, runs upward near and parallel to 
the coronal suture toward the longitudinal sinus, and it at times is 
accompanied by the sphenoparietal sinus in a part of its course. The 
smaller posterior branch crosses the squamous portion of the temporal 
bone and continues along the line of junction of the squamous and petrous 
portions of the temporal bone to the posterior inferior angle of the parie- 
tal bone, to divide into its final branches. On account of its position in 
the groove of the great wing of the sphenoid and also in the groove and 
canal of the parietal bone and its course through the foramen spinosum, 
it readily can be seen how fractures in this region may open the vessel, 
either from alteration in the shape of the canal or foramen or by spicules 
of bone piercing its coats. The large hemorrhages external to the dura 
occasionally found in such arterial lacerations are accounted for by the 



FEACTUBES OF THE CRANIUM 



143 



looseness with which the dura is attached to the cranium at this position. 
Most of the cerebral symptoms seen in fracture in this position are motor 
in character, because the intracranial bleeding from a torn middle menin- 
geal artery compresses the brain in its motor area. 

The principal fissures of the cerebrum are the longitudinal, the 
Sylvian, the Rolandic and the parieto-occipital. 

The nasion, or the nasofrontal suture, and the temporal ridge marking 
the upper attachment of the temporal fascia and muscle, are topographi- 
cal points of the cranium easily located (Figs. 121a and 121b). The exter- 



Fig. 121a. 



Fig. 121&. 





/: 



FlGS. I2ia and 1216. — Craniocerebral localization: i-l', Reid's base line; 2-2', supraorbital line; 3, middle 
meningeal artery; 4, anterior branch; 5, the site for trephining for the anterior branch; 6, the posterior 
branch; 7, the site for trephining for the posterior branch; 8, the lateral sinus; 9, the inion; 10, the mastoid 
process; n, the facial nerve; 12, the temporal crests; 13, the temporal fossa. (Modified after Rawling.) 

nal angular process is the outer extremity of the frontal bone where it 
articulates with the malar bone. The stephanion is the point where the 
temporal ridge crosses the coronal suture. 

The lower level of the brain may be approximately determined by a 
line drawn horizontally across the frontal region through the upper part 
of the glabella. This line should be continued from the external angular 
process of the frontal bone through the preauricular fossa to the external 
occipital protuberance. The cerebellum will be found between the latter 
portion of this line and a line drawn from the mastoid process to the inion. 

The base of the cranium (Fig. 122) may be divided into three fossae : 
the anterior, the middle, and the posterior. In fracture of the base in- 
volving the anterior fossa, blood may enter the orbit and produce a 
subconjunctival ecchymosis, or in conjunction with cerebrospinal fluid 
it may escape from the anterior nares or posterior nares. The blood- 
producing subconjunctival ecchymosis may come from rupture of the 
meningeal vessels, the ophthalmic artery or vein, or the outer anterior 
or posterior ethmoid vessels. Bleeding from the nose may be indication 
of rupture of the nasal vessels. Hemorrhage may also occur in the nose 



1U 



TEEATISE OX FRACTURES 



through rupture of the meningeal vessels in fracture of the cribriform 
plate of the ethmoid. Hemorrhage about the eyelids and subcutaneous 
tissue of the orbit may be the result of a blow from the outside and not 
as result of fracture of the cranium. In fracture of the middle cerebral 
fossa blood and cerebrospinal fluid may escape from the ear. For this 
to occur there must be a laceration of the arachnoid, dura mater, mucous 
membrane of the wall of the tympanum, and the tympanic membrane, 
in addition to fracture of the base of the skull. Fracture of the middle 
fossa may involve the sphenoid or basilar process of the occipital bone and 
produce bleeding into the mouth. It may also cause an accumulation 




Fig. 



122. — The inner surface of the base of the skull, showing the limits of the anterior, the middle and the 

posterior fossa. 



of blood posterior to the pharynx. In fractures involving the posterior 
cerebral fossa bleeding may show in the posterior triangle of the neck. 

The cranium varies in density and rigidity in different parts and in 
different individuals. In speaking of fractures of the " cranium," the 
word " skull " is often used rather inaccurately for cranium. The 
cranium derives its rigidity and strength from its shape, the thickness 
of the bone entering into its formation, and from the presence of thick- 
ened bone in certain places, which forms buttresses running from the base 
to the vault. The vault is strong, not only on account of its shape, but 
also on account of the presence of the two tables separated by diploic 
tissue. The diploe is most abundant in the frontal, parietal, and upper 
occipital regions. These regions are unusually strong in contrast with 
the squamotemporal and cerebellar regions, in which there is very little 



FRACTURES OF THE CRANIUM 

Fig. 123a. Fig. 123&. 



145 





Fig. 123a. — Calvarium, transverse fracture of the vault. The fracture may be traced 
from the squamous portion of the left temporal region through the parietals, crossing the 
sagittal suture close to the occipital bone, into which the fracture passes behind the temporal 
bone. Patient fell upon sidewalk; symptoms of compression resulted and death occurred 
in 12 hours. A clot of blood displaced the dura mater under the parietal bones. (Mutter 

Museum, No. 11-51.37.) 
Fig. 123Z;. — Skull. Fracture of the base. In this instance there is evidence of a point in 
the frontal region where the blow was received; no fracture is, however, visible at this situa- 
tion. The occipital bone is seen to be fractured into three fragments; the line of fracture 
diverges from a point immediately below the superior curved line 2 cm. to the right of the 
ligamentum nuchae; from this point one line passes upward to the superior angle of the bone, 
another obliquely, toward the left mastoid process, the third nearly to the right styloid 
process. (Mutter Museum, No. 1151.03.) 




Fig. 124. — Skull without calvarium; fracture of the right temporal and parietal 
bones. Recent. The line of fracture passes from the anterior border of the squamous 
portion of the right temporal bone horizontally backward through the posterior 
portion of the right parietal to the occipital bone near the superior angle. (Mutter 
Museum, No. 1 151.04.) 



10 



14:6 



TEEATISE OX FEACTL T EES 




Fig. 125. — Rontgenogram showing fissured fracture of cranium. Line of fracture extends antero- 
posterior^ in vault with supplementary lines extending into posterior fossa at base. Child one year 
of age, fell from the arms of grandfather while being carried. 



... 



Fig. 126. — Rontgenogram of fissured fracture of vault of skull, occipital region. 



FRACTURES OF THE CRANIUM 147 

diploic tissue. In the base certain areas are strengthened by buttress-like 
thickenings, which extend upward from the crista galli, from the external 
angular process, from the auditory region, and from the occipital pro- 
tuberance. Parts intervening between these buttresses are the weak areas 
at the base. The elasticity of the skull may be demonstrated by letting 
it fall upon the floor ; it does not immediately remain at rest like a non- 
elastic body, but makes several bounds like a baseball or an ivory sphere. 
Etiology. — Fractures of the cranium are the result of direct or indirect 




Fig. 127. — Comminuted fracture of skull, frontal region. 

violence acting upon the skull; and the resulting lesion depends in a 
great measure upon the site to which the violence is applied, its character, 
and the method of injury. The lesion may consist, if only the vault of the 
skull is involved, in a fracture of the outer table, of both the outer and 
the inner tables, or rarely of the inner table alone. About two-thirds of 
fractures of the vault are complicated by lines of fracture extending to the 
base of the skull. Fractures may be classified as fissures, comminuted, 
diastasis of sutures, depressed, perforated, elevated, and gunshot. 

Fissured Fractures (Figs. 123 and 126). — This variety is generally 
seen as a single line of fracture with very little if any inequality of the 



us 



TEEATISE OX FBACTURES 



two edges of the bone forming the line of separation. They are most 
commonly seen at the base of the skull and are the result of either bending 
or bursting forces. The fissure may involve several bones, and the split 



Fig. 128a 




Fig. 128c. — Skull; lower half; fracture of the base. Recent. The fracture is extensive, passing from 
the right temporal bone through the sella turcica to the left temporal. On the right side the greater 
wing of the sphenoid is fractured, on its extremity, the lesser wing through the median line, and the 
body transversely in the posterior portion of the sella turcica; then the fracture passes just anterior to 
the left auditory canal and through the squamous portion to the upper border of the temporal bone. 

(Mutter Museum, No. 1151.06.) 
Fig. 1286. — Skull; extensive fracture involving the right parietal, frontal, temporal, occipital and 
sphenoid bones. Woman struck with a pole of an axe while asleep. (Mutter Museum, No. 1151.42.) 



Fig. 129. 



Fig. 130. 




Figs. 129 and 130. — Calvaria. Fracture of the right parietal bone. The line of fracture extends 
upward from the base to the vault, involving the right parietal and a portion of the left parietal. 
This shows well how the line of fracture is not affected by the sutures. (Mutter Museum, Brinton 

Collection.) 

may run in a straight line irrespective of the direction of sutures. While 
the fissure generally occurs as a single crack, it may be forked or have a 
multiple character. Sometimes it is impossible to recognize a fissured 
fracture during life on account of the symmetry of its edges. At times, 
if the fracture is compound, portions of hair or clothing may be caught 



FRACTURES OF THE CRANIUM 



149 




150 



TREATISE OX FRACTURES 




and held between its edges. It is doubtful whether a fissured fracture 
may be detected by percussion alone or combined with auscultation. Fis- 
sured fractures may occur alone or in combination with depressed or 
gunshot fractures. 

Comminuted fractures (Figs. 127-132) are usually the result of direct 
violence applied over a small area, and occur most frequently in the vault 
of the cranium. They are characteristic of fractures by bending. They 
may involve a very small area or be distributed over a large surface. The 
fragmentation may consist of two or many pieces. 

Fractures by Diastasis (Fig. 133). — Traumatic separations of cranial 

sutures, perhaps better called 
diastases, are similar to fissured 
fractures. They may be asso- 
ciated with a fissure or com- 
minuted fracture in which the 
line of separation is deflected 
into a suture. These separa- 
tions are only seen during early 
or adolescent life, before the 
adjacent bones forming suture 
lines have ankylosed. In later 
life the condition cannot be 
truly described as a diastasis, 
because the sutures have ossi- 
fied. Lines of fracture, how- 
ever, may occur along these 
ossified sutures in conjunction with fissured or comminuted fractures. 

Depressed Fractures (Figs. 134-137). — There are three varieties of 
uncomplicated depressed fracture : Fractures involving the outer table 
alone, the so-called pond and gutter fractures, and fractures involving 
both tables of the skull. These varieties of depressed fracture are the 
result of direct violence applied to the vault of the cranium over a small 
area, and are usually due to blows with a heavy instrument like a hammer 
or to the impact of an object falling from a height. 

Depressed fractures involving only the inner table of the cranium also 
occur. These are produced by a circumscribed blow applied to an elastic 
skull when the force applied is not great enough to produce fracture 
and depression of both tables. Then only the more brittle inner table, 
which has no support beneath it, gives way. This form of fracture is 
very rare and difficult to determine except by X-ray plates. Depressed 
fractures have peripheral hollows, when one portion of the fragment 
that is driven in is attached to the intact bone and the other slopes toward 
the centre of the depressed area. Central depressions occur when the 
entire depressed fragment is below the level of the intact bone. 



Fig. 133. — Skull; fracture of the superior angle of the 
occipital bone with fracture of both temporal bones in 
horizontal lines separating the squamous from the mas- 
toid portions and passing through the auditory canals. 
(Mutter Museum, No. 1 151. 21.) 



FEACTUEES OF THE CEANIUM 



151 




Fig. 134- — Rontgenogram showing depressed comminuted fracture of skull, parietal region. 
Fig. 135a. Fig. 135b. 




Figs. 1350 and 135b. — Calvarium; fracture of the right parietal, compound comminuted, and depressed. 
The injury was from a sling-shot received immediately above the temporal bone. There are no radiating 
fissures, but there is depression of a portion of the parietal immediatelv over the temporal bone; the 
area is greater in the inner table than the outer table. Trephining was performed immediatelv. There 
were symptoms of compression. Death occurred in two davs. (Mutter Museum, Xo. 1 151.35.) 



152 



TEEATISE OX FBACTUBES 

Fig. 136a. _ Fig. 1366. 




Fig. 136a. — Calvarium. Depression of the right parietal. In the posterior portion of the right parietal 
there is a circular depression having a diameter of from 4 to 5 cm. and a depth of 7 cm. A corresponding 

depression is seen on the inner side. Evidence of fracture is seen. (Mutter Museum, Xo. 1 151. 14.) 

Fig. 1366. — Calvarium; depressed fracture of the left parietal bone 5.5 cm. long in the left parietal 

bone parallel to the interparietal suture. The fracture was probably made by a single blow of a sharp 

instrument. Both tables involved. (Mutter Museum, No. 1151.11.) 



Fig. 137a. 



Fig. 1376. 




Fig. 137a. — Anterior half of calvarium. Punctured fracture at three points with depression of the 
internal table. _ Boy, 16 years, fell upon a large wheel covered with spikes of polished iron 9 cm. long, 
sharp at the points and 6 mm. at the base. It was practically a revolving comb for disentangling hemp. 
The boy was impaled on the hooks and it required two men to release him. Symptoms of meningitis 

and later tetanus developed and boy died at end of ten days. (Mutter Museum, Xo. 1151.10.) 

•Fig. 137ft. — Calvarium; fracture of left frontal and both parietals. Recent. The fracture evidently 

was made by a saw. There is an opening 13 cm. long of irregular shape situated in the left frontal and 

parietal bones. (Mutter Museum, Xo. 1 151.09.) 



FRACTURES OF THE CRANIUM 



153 



Penetrating and Perforating Fractures (Figs. 138 and 139). — Breaks 
of the cranium occurring as a result of impact from a blunt instrument 
or missile or a sharp weapon, which has force sufficient to enter the 
interior of the cranium, are a form of complicated fracture. The cranial 
cavity may be only penetrated or its opposite wall may be broken and the 



Fig. 1380. 




Fig. 1386. 




Fig. 138a. — Photograph of outer table of skull showing contusion without fracture by a 

conoidal musket ball. 
Fig. 138&. — Inner table of same skull with fracture. A fragment an inch and a half in length 
and half an inch broad completely detached from vitreous table. (Specimen from Civil War, 
1861-65. A. M. M. Collection. Legarde's Gunshot Injuries. Wm. Wood Co.) 



Fig. 139a. 



Fig. 130&. 





Fig. 139a. — Photograph of a gunshot contusion, outer table of skull without fracture, by a 

conoidal musket ball. 
Fig. 139&. — Inner table, same skull, showing fracture with depression opposite the point of con- 
tusion on outer table. Dura was lacerated. (Specimen from Civil War, 1861-65. A. M. M. Collec- 
tion, Legarde's Gunshot Injuries. Wm. Wood Co.) 



vulnerating body pass through it. The former constitutes a penetrating 
fracture, or wound, of the cranium ; the latter is a perforating wound, 
or fracture. As a rule all perforating fractures are associated with de- 
pression, comminution of fragments, and severe intracranial injury. 



154 TREATISE OX FRACTURES 

Fragments of bone may be driven deeply into the brain. Perforating 
fractures obviously are open fractures. Gunshot fractures are usually 
penetrating or perforating fractures. 

Elevated fractures of the cranium are rare and are seen mainly in 
military life. They result generally from sabre cuts, and may involve 
either the outer table alone or both tables together. 

'Gunshot fractures, involving the upper or posterior regions of the 
skull, deserve some special consideration. The form of fracture and the 
extent of injury to the intracranial organs depend upon several factors. 
The lesion produced is dependent upon the nature, size, and velocity of 
the bullet, the angle of impact, and particularly upon the distance from 
which the bullet is fired. Von Bergmann states that with the modern, 



^ 




N 



urn, ,wa ( ■■ii. hwfffiri * . m « m t »m*m^ J* -, 



A 



V 



^ ^vX 



Fig. 140. — Diagrammatic illustration showing effects of a perforating bullet 
wound of skull and brain. (Modified after Rawling.) 

hard shell, high-velocity bullet at short range, the skull cap, together 
with the scalp covering it, is torn off. At a range of 50 metres there is 
a wound of entrance and one of exit, the scalp is preserved, and the skull 
held together, although the latter was broken into many fragments. At 
100 metres there is less destruction of the skull; and the lines of fracture 
are arranged radially, in part encircling the bullet holes like a bending 
and bursting fracture. The diameter of the wound of exit is about 20-30 
mm. At 800 to 1200 metres the Assuring encircling the bullet holes dis- 
appears, and only radial fissures are present. At 1600 metres these 
latter disappear, except that there is one fissure connecting the wound of 
entrance with the wound of exit. This latter disappears at 1800 to 2400 
metres, and the wounds of entrance and exit are clean-cut bullet holes. 
At 2700 metres the skull is not perforated, the bullet remaining in the 
brain. The above experiments were made with a hard lead, steel-mantled 



FEACTUBES OF THE CRANIUM 155 

bullet, fired from a small-calibre arm and had an initial velocity of 2000 
feet per second. The lesions of the bone are complicated by and intensi- 
fied by that of the brain itself. It has been shown by v. Coler that there 
is an explosive action upon the brain proportionate to ; the distance from 
which the bullet is fired. These changes range from total removal of the 
brain from the shattered skull in short distances to simple perforations 
at long distances, and finally to simple concussion when the bullet does 
not penetrate the skull at all. The results produced by the pistol bullet 
at short range are more or less similar to those produced by the modern 
high-velocity bullet fired from a rifle at long range, according to 
v. Bruns. Depending upon the angle of impact, there may be perforated, 
gutter, and depressed fractures of varying degrees. 

The wound of the skull is more or less dependent upon the size and 
shape of the bullet. The composition of the bullet and the fact of its 
having a hard steel jacket or not will greatly influence the resultant bone 
lesion. Bullets having a soft nose, the so-called dum-dum bullet, have 
an explosive action. 

The wound of entrance shows changes in the internal table similar 
to that of the external table at the point of exit, influenced, of course, 
by the projectile having passed through the brain. The bullet may have 
somersaulted, and the wound of exit may be made by the blunt rear end 
of the bullet. Ordinarily the wound of exit has the edges everted, por- 
tions of bone may be found in the scalp, and the wound is larger than that 
of entrance (Fig. 140). 

Of utmost importance in gunshot fractures of the skull is the injury 
to the brain (Figs. 141 and 142). These changes vary from a single 
track, with points of entrance and exit, with extravasation in neighboring 
areas, to a condition in which the brain resembles a hemorrhagic pulp. 
The latter condition is the result of close range bullet wounds, in which 
the disintegrating and pulpefying of the brain is produced by the expansile 
effect of the bullet and is accompanied by hemorrhage into the ventricles 
and meninges. The condition is invariably fatal. Further discussion 
of cranial fractures caused by missiles, set in motion by sudden explosive 
forces is given in the chapter on gunshot fractures. 

Fractures of the Vault of the Cranium. — Fractures of the vault of 
the skull may be the result of violence applied directly to the vault or 
may be due to' the extension of a fracture of the base. Fractures of the 
vault are complicated by fractures of the base in about two-thirds of the 
cases. Fractures of the vault are often open, and, when so, are more liable 
to limitation to the vault. Fractures of the vault depend upon the site 
of the application of the force, the direction of the force, and the degree 
of violence used. Most fractures of the vault are by direct violence, and 
those of the base by indirect violence. Exceptions to the latter are gun- 
shot wounds of the base through the mouth or orbit. Fractures of the 
vault may be confused with hematoma of the scalp, in which depression 



156 



TEEATISE OX FRACTURES 



of the skull may be considered. Hematoma may be recognized by the 
disappearance of the ring on deep, firm pressure, the bluntness and 
smoothness of outline, by the fluctuation and softness of its centre, and 
by the minor degree of cerebral disturbance. If in doubt, or there 
are symptoms of compression, the surgeon should treat hematoma as a 
depressed fracture. 

Fractures of the Base of the Cranium. — Fractures of the base of the 



Fig. 141. 



Fig. 142. 




Fig. 141. — Gunshot wounds of head with fractures of skull. Shows two wounds of entrance. First is close 
range with powder marks surrounding it; second, close range with actual contact and extensive gas wound 

which has caused two extensive rips in the skin. (Courtesy of Dr. Wm. S. Wadsworth.) 

Fig. 142. — Shows the base of the brain case with two probes indicating direction of bullets. One passed into 

middle fossa, caused a number of lines of fracture in anterior and middle fossa indicated by marks. The 

other passed backward, caused extensive bleeding, and caused a general group of fractures in the left 

occipital region. (Courtesy of Dr. Wm. S. Wadsworth.) 

cranium are usually the result of indirect violence, applied upon the vault 
and transmitted to the base. They may occur from direct violence. 
Gunshot and other perforating wounds of the mouth or orbit, the driving 
upward of the condyles of the inferior maxilla against the socket 
by a blow upon the chin (Fig. 143), a blow upon the nose, a fall upon 
the feet or buttocks with transmission of the force through the spinal 
column, may cause fracture of the base of the cranium in the anterior, 
middle, or posterior fossa. These are instances of fracture due to direct 
impact upon the bones of the base. 



FBACTUBES OF THE CRANIUM 



157 



Mechanism of Fractures at the Base. — The mechanism of fractures 
of the skull differs from that of all other fractures. This is due to a 
number of factors, the principal of these being the hollo wness, shape, 
and elasticity of the skull. Many theories have been given from time to 
time to account for the types, locations, and varieties of fractures. This 
is especially the case in those involving the base of the skull. Various 
physical laws have been deduced to account for the pet theories 
of each exponent. Many clinical and experimental investigations have 
been carried out for solving the elementary principles of basal fractures. 
Of these the most important theories are as follows : 

Aran's theory of irradiation was that fractures of the base are 




Fig. 143. — Illustrates possibility of fracture of the base of the skull 
by transmitted force applied to the lower jaw through the condyle, 
on account of the thinness of the glenoid fossa (marked by arrow). 
The posterior part of the zygomatic process has been removed for 
clearness of demonstration. 



due to extension from a fracture of the vault and that the lines of fracture 
follow the shortest anatomical route to the base. It presupposes the 
coexistence of vault and basal fractures. The theory was modified after 
observations made by v. Bruns upon the elastic properties of the cranium. 
The conclusion was that these fractures are the result of changes in 
form, and that the lines of fracture occur along the line of least cohesive 
resistance toward the pole of impact. This theory has received the 
support of Messner, Hermann, and von Wahl. 

The Bursting Theory. — This is founded upon the elastic and 
cohesive properties of bone. Compression of one pole of the cranium 
toward the other produces a diminution in the diameter of the axis 



15; 



TEEATISE OX FRACTURES 



with bulging of the other diameters, most marked at a right angle to the 
line of pressure. When this bulging exceeds the normal elasticity and 
cohesiveness of bone, a fracture occurs, the line of fracture depending 
upon various factors. When the fracture occurs on a line parallel to the 
line of the compressing force the cranium breaks along the convexity 
and a bursting fracture is produced; when the line of fracture is at right 
angles to the compressing force the lesion is termed a compression frac- 
ture. Rawling takes exception to these theories on the grounds that they 
are based upon experimental fractures produced by compressing the head 
of a cadaver in a tight-fitting box; the cases of bilateral compression 
are of infrequent occurrence, and that the great majority of basal 



Fig. 144. 



Fig. 145. 




Fig. 144. — Line of fracture of base, from force applied to the median frontal region. (After Rawling.) 
Fig. 145. — Line of fracture of base, from force applied to the lateral frontal region, near the external 

angular frontal process. (After Rawling.) 



fractures are the result of blows applied directly at the level of the base 
or of violent forward propulsion of the body, the head coming in contact 
with the resisting object. The cranium, he contends, cannot be regarded 
as a sphere, because it forms only about two-thirds of a sphere, and does 
not possess requisite elasticity to account for fracture by this means. 

The coxtrecoup theories were first propounded by the French 
surgeons, and though one or other has been accepted by many, they are 
doubtless mechanically unsatisfactory explanations. One of the theories 
based on the contrecoup doctrine is that, through molecular oscillation, 
there are waves of vibration sent from the point of impact to the opposite 
pole and that these radiating waves meeting produce a local lesion, 
although they are of sufficient force to produce a fracture at the point 



FEACTUBES OF THE CEANIUM 159 

of impact. Other theories are that, through the influence of hydrostatic 
pressure carried through the brain and cerebrospinal fluid, the bone is 
fractured at a point opposite that of impact. 

Rawling's Theory of Direct Violence. — From an investigation 
of over 300 cases of basal fracture Rawlings has obtained the following 
results : In about 30 per cent, of cases it was possible to show that the 
fractures of the base were direct extensions from fractures of the vault 
(Aran's theory of irradiation). In about 5 per cent., the fracture resulted 
from falls upon the buttocks and from blows applied to the angle of the 
jaw. In over 60 per cent, of cases the fractures were the result of direct 
violence applied at or near the basic level, the line of fracture passing 
across the base in the general line of applied force. He also considered 
that all blows applied at or near the basic level tend " primarily to involve 
the weaker area, the base, passing secondarily upward on to the vault." 

Rawling's rules with respect to the probable line of transbasal fracture 
from a study of over 300 cases are: 

■" Probable resultant basic fracture varying with the direction, etc., 
of the applied force : (1 ) Force applied to the median frontal region (Fig. 
144). The fracture passes backward from the perpendicular plate of the 
ethmoid, thence between the optic foramina to the body of the sphenoid. 
The fracture diverges to the opposite side, and, tearing off the posterior 
clinoid process, passes along the petro-occipital suture to the jugular fora- 
men, being then continued on the other side of that foramen along the 
masto-occipital suture, and again to the vault. 

"(2) Force applied to the lateral frontal region, in the situation 
of the external angular frontal process (Fig. 145). The fracture passes 
along the anterior fossa towards the sphenoidal fissure, tearing away 
the anterior clinoid process, and again comminutes the roof of the sphe- 
noidal sinus. Progressing onwards with or without fracturing the pos- 
terior clinoid process, the fracture passes either along the anterior part 
of the petrous bone at its junction with the greater wing of the sphenoid 
towards the opposite middle and external ears, or along the petro-occipital 
suture to the jugular foramen, and is continued along the masto-occipital 
suture as in the previous case. 

"(3) Force applied to the region of the external ear (Fig. 146). The 
fracture passes across the roof of the bony auditory meatus towards 
the junction of the anterior and inner walls of the middle ear, the mem- 
brane undergoing a variable amount of destruction and displacement. 
The fracture is then continued across the tegmen tympani, and, after fol- 
lowing the petrosphenoidal suture, reaches the foramen lacerum medium, 
being again continued on the opposite side of that foramen to the sphe- 
noidal body. Thence it pursues one of two courses. Most commonly 
the fracture passes backwards obliquely to the opposite middle and exter- 
nal ears, following a course similar to that already indicated. 



160 



TREATISE OX FRACTURES 



"(4) Force applied to the mastoid region (Fig. 147). The fracture 
follows the occipitomastoid suture to the jugular foramen, and is again 
continued to the opposite side of that foramen along the petro-occipital 
suture towards the apex of the petrous bone. It then passes across the 
sphenoidal body to the sphenoidal fissure of the opposite side, and so across 
the anterior fossa. It is especially common in this particular variety of 
fracture to find fissures diverging from the region of the sphenoidal sinus 
forwards towards the cribriform plate of the ethmoid, these fissures 
usually passing between the optic foramina. 

" This fracture is also peculiar in that, when the degree of separation 



Fig. 146. 



Fig. 147. 




Fig. 



a-a, the 



[46. — Lines of fracture of base, from force applied in the region of the external ear. 
"typical" basic fracture. (After Rawling.) 
Fig. 147. — Line of fracture of the base, from force applied in the region of the mastoid. (After Rawling.) 



along the occipitomastoid suture is excessive, there is special liability to 
a tearing of the lateral sinus wall as the sinus begins to turn downwards 
and inwards. 

"(5) Force applied to the lateral occipital region (Fig. 148). The 
fracture passes across the thin cerebellar fossa and strikes the foramen 
magnum immediately behind the condyle. Starting again from a similar 
point on the opposite side of the foramen, the fracture passes outwards 
to the jugular foramen. Two courses are now possible : the fracture 
either runs outwards across the body of the petrous, ' external ' to the 
internal auditory meatus, and. cutting across the facial nerve in the 
region of the geniculate ganglion, finally terminates in the roof of the 
middle ear, or else passes along the petro-occipital suture to the foramen 
lacerum medium, the sphenoidal fissure, and the anterior fossa as in 
the previous case. 

"(6) Force applied to the posterior occipital region (Fig. 149). The 



FBACTUBES OF THE CKANIUM 



161 



resultant fracture varies according to the direction of the applied force. 
A force which is applied to the transverse axis of the skull results in 
a fracture, which, on reaching the posterior margin of the foramen mag- 
num, is continued again on the opposite side of the foramen along the 
dorsum ephippii. When the force is more oblique in direction, as- is 
usually the case, the fracture traverses the thin cerebellar fossa to the 
outer margin of the jugular foramen, and then follows one of the two 
courses indicated in the previous case. 

" More commonly the fracture cuts across the petrous bone." 
Symptoms of Fracture of Vault of Cranium. — As a rule the subjective 



Fig. 148. 



Fig. 149. 




FlG. 148. — Line of fracture of the base, from force applied to the lateral occipital region. (AfterRawling.) 
Fig. 149. — Lines of fracture of the base from force applied to the posterior occipital region. (After Rawling.) 



symptoms are of little use in arriving at a diagnosis of suspected fracture 
of the cranium. Fracture may show no special symptoms different from 
those associated with various forms of intracranial injury. 

Fractures of the vault without intracranial lesions are at times very 
difficult to diagnose. This is especially true in those which are un- 
accompanied by wounds of the scalp. When there is a circumscribed 
fracture of the vault there is generally a scalp wound through which 
the skull may be directly examined and a proper diagnosis made. In these 
patients a digital examination should be made after thoroughly cleansing 
the wound ; if necessary the wound should be enlarged for the purpose. 
Fissured, depressed, comminuted, and perforated fractures may thus 
readily be recognized. In closed fractures the diagnosis may be obscured 
by the coincidence of a subaponeurotic or subpericranial hematoma. The 
11 



162 TREATISE OX FKACTUKES 

differential diagnosis of these two conditions is not always easy without 
exploration. It is justifiable to incise the scalp for diagnostic purposes, 
whenever there are symptoms pointing to probable depression of frag- 
ments or localized intracranial injury, or when the character of the 
traumatism makes it likely that the bone may be broken. An aseptic 
incision of the scalp is practically without danger; but an undiscovered 
fracture, particularly of the punctured kind, may lead to secondary 
epilepsy or other serious sequel. When there is doubt as to the treatment 
to be pursued because the existence of fracture is not established, it is wise 
to incise the scalp for exploration. In intracranial injury the symptoms 
may be due to the occurrence of cerebral laceration, or cerebral pressure 
from fragments or from blood clots resulting from damage, to the middle 
meningeal artery or other vessels. In addition there may be fixed pain 
in certain regions, symptoms of compression as shown by combined or 
partial paralysis of the opposite side of the body, late evidence of encepha- 
litis, or suppuration. The symptoms of cerebral concussion, cerebral 
irritation, and cerebral compression will be referred to briefly later. 

All fractures of the vault should be radiographed in several directions 
and the diagnosis of a fracture may be facilitated by this means. When 
radiography is not available the surgeon should not allow the patient to 
suffer because he is too timid to cut down upon the injured region. It 
is proper to open the scalp to examine the bone, and to trephine the bone 
to examine the brain. Delay from doubt may be more risky by far than 
aseptic operation for exploration. This means that aseptic procedures 
are often necessary for diagnostic and therapeutic purposes. 

Symptoms of Fracture of the Base of the Skull. — The principal symp- 
toms of fracture of the base of the skull are hemorrhage, the escape of 
cerebrospinal fluid, or of brain matter, the exit of air from the air 
sinuses into the surrounding tissues, disturbance of cranial nerves, pupil- 
lary changes, and temperature changes. 

Most of the symptoms may be grouped in relation to fractures in- 
volving one or more of the fossae of the skull. 

Anterior Fossa. — Hemorrhage from the nose or mouth is generally 
present in fracture of the anterior fossa involving the cribriform plate 
of the ethmoid. Retinal hemorrhage is observed when there is associated 
hemorrhage into the subarachnoid space. Orbital hemorrhage, causing 
proptosis, has its origin in a fracture associated with injury to the 
cavernous sinus or internal carotid artery, in a fracture of the orbital walls 
and laceration of the ethmoidal vessels, or in a fracture of the sphenoidal 
body complicated by a fistula between the cavernous sinus and internal 
carotid artery. Palpebral, peripalpebral and subconjunctival hemorrhage 
is not always diagnostic of fracture involving the anterior fossa. It may, 
however, be present in fracture involving the perpendicular plate of the 
frontal or the cribriform plate of the ethmoid bone. 

Fleming reported twelve cases of fracture of the skull, eleven of 



FBACTUBES OF THE CEAXIUM 



163 



them being fractures of the base, and in all of these there was 
retinal hemorrhage. 

Middle Fossa. — Hemorrhage may occur from the mouth or ear. This 
is possible because most fractures of the middle fossa involve the external 
auditory canal, the inner and anterior walls of the middle ear, the mem- 
brana tympani. The blood escaping from the ear may be derived from 
the vessels of the lining membrane of the external and middle ears, from 
the tympanic vessels, from the lateral sinus, or from the middle meningeal 
artery. Profuse and long-continued hemorrhage from the external ear 
generally means injury to the lateral sinus or middle meningeal artery 
(Figs. 150 and 151). 

Crandon and Wilson give the following statistics in reference to 



Fig. 150. 




Fig. 151. 



Cavernous Sinus. 
Third nerve- 
Internal carotid 
artery 




Fig. 150. — Fracture of the base with laceration of the carotid arteries. (After Rawling.) 
Fig. 151. — Fracture of the base with laceration of the cavernous sinus. (After Rawling.) 

hemorrhage from the ears, nose and mouth, and mortality in fractures 
involving the middle fossa : 

Hemorrhage from the ear 281 170 in 39 per cent. 

Hemorrhage from both ears 47 16 31 66 per cent. 

Hemorrhage from the nose 44 17 27 61 per cent. 

Hemorrhage from the mouth ......... 168 ~t, 93 ^7, per cent. 

D wight has shown from a study of 146 cases of fractures of the skull, 
studied at autopsy, that in 69 per cent, of cases of fracture of the middle 
fossa there was bleeding from the ear, and that in 29 per cent, of cases 
there was an associated laceration of the middle meningeal artery. 

Hemorrhage from the mouth may have its source in lacerations of 
the sphenoidal or pharyngeal vessels, or from the internal carotid artery 



164 TREATISE OX FRACTURES 

or cavernous sinus, complicating fractures of the sphenoid body and 
laceration of the pharyngeal wall. 

Hemorrhage in the temporal region is generally seen in fracture in- 
volving the temporal fossa, the blood being either confined to the temporal 
region, forming a temporal hematoma, or it may be diffused throughout 
the subaponeurotic space. 

Posterior Fossa, — Hemorrhage in fracture of this fossa is often late 
in appearing, and is frequently confined to the subtentorial region; if 
the discoloration does not involve the soft parts, the hemorrhage may 
make itself evident as a boggy ecchymotic area diffused over the posterior 
surface of the scalp, the neck, and the mastoid region. 

A flow of cerebrospinal fluid may take place from the nose, mouth, 
or ears, and is generally diagnostic of fracture of the base of the skull, 
associated with rupture of the overlying dura and arachnoid membranes. 
The source of the fluid is the subarachnoid spaces. Crandon and Wilson 
reported 2J instances in which escape of cerebrospinal fluid was present 
out of 530 cases. Phelps found 13 in a series of 286 cases of fracture 
of the base; and Anna Heer recorded 58 cases of fracture of the base, 
in 2.7 of which there was an escape of cerebrospinal fluid from the ear and 
in 2 from the nose. 

Fractures involving the anterior fossa may be associated with the 
escape of cerebrospinal fluid from the nose, in which case there is generally 
a fracture. of the cribriform plate of the ethmoid. The escape of cerebro- 
spinal fluid from the nose, mouth, or ears may be seen in fractures involv- 
ing the middle fossa. The presence of fluid flowing from the external 
auditory meatus generally means fracture of the middle fossa. Rawling 
is of the opinion that the escape of cerebrospinal fluid is an infrequent 
symptom of fracture of the middle fossa: but states that fractures, 
originating in the posterior fossa, may cut across the petrous portion of 
the temporal bone in such a manner as to sever the seventh nerve and 
to tear the dural and arachnoid prolongations of that nerve. In such 
lesions there will be a discharge of cerebrospinal fluid from the ear, 
if the tympanic membrane is ruptured; but if there is no injury to this 
membrane, the escape of cerebrospinal fluid will take place from the 
nostrils or nasopharynx by means of the Eustachian tube. 

The escape of cerebrospinal fluid may begin immediately after the 
injury and may be very profuse. Yon Bergmann states that in some 
cases there may be from 150 to 200 grammes collected in twenty-four 
hours, and Stimson refers to a case in which 63 ounces were collected 
in four and one-half days. Sir W. MacCormac reports a case in which 
10 pints escaped within five hours. The cerebrospinal fluid escaping 
from the nose, mouth, or ears should be of the same chemical character 
as that found normally in the subarachnoid spaces. It should be alkaline 
in reaction, contain a trace of albumin, be rich in sodium chloride, and 
should show a trace of a reducing substance allied to pyrocatechin. The 



FRACTURES OF THE CRANIUM 165 

escape of cerebrospinal fluid from the nose, mouth, or ears may be con- 
taminated with normal discharges from these orifices, and render the tests 
noted valueless. Generally the fluid is at first blood-stained. Other 
sources of error are seen in the escape of the liquor cotunnii, a fluid 
which is highly albuminous and contains no chlorides, which has its 
origin from the large perilymph spaces of the labyrinth. Another source 
of error is a serous discharge from the mucous membrane of the ear 
or nose, which can be differentiated from cerebrospinal fluid by its chemi- 
cal characteristics. Inflammatory discharges from these two surfaces 
may also be profuse and lead to error, or be the sources of contamination. 
The serum from extravasated blood may lead to error. In this instance it 
is not very profuse, is reddish, albuminous, and does not appear imme- 
diately after the injury. 

The escape of brain tissue is of very rare occurrence. Rawling has 
observed one case of escape of brain tissue from the nose and one from 
the ear in a series of 300 cases. Its presence is a positive sign of fracture 
of the skull and also of laceration of the dura and arachnoid. There is 
generally considerable comminution of bone, such as occurs in crushing 
injuries. In a case of one of the authors, in which the head was injured 
in an elevator accident, there was subsequent discharge of brain tissue 
from the nose. The post-mortem examination showed extensive com- 
minuted fracture of the base involving the cribriform plate of the eth- 
moid. The escape of brain tissue from the external auditory meatus 
necessitates a fracture involving the superior wall of the auditory canal, 
rupture of the tympanic membrane, and also of the dura and arachnoid. 

Emphysema of the surrounding soft parts may take place when the 
line of fracture involves the frontal, ethmoidal, mastoid, or sphenoidal 
sinuses, and there is a sudden increase of intrasinal air pressure. This 
condition is seen most frequently after fracture of the frontal bone in- 
volving the frontal sinus, very rarely after fracture involving the sphenoid 
bone and mastoid process. The emphysema may be circumscribed or it 
may be diffused. It is circumscribed when the overlying pericranium is 
not torn, and it may be diffused when the pericranium is torn. At times 
the emphysema in fracture involving the frontal sinus may spread over 
the face, neck and chest ; in fracture involving the mastoid region it may 
spread through the subaponeurotic space to the scalp and the cellular tissue 
of the neck. Its presence is readily determined by palpation, which reveals 
the peculiar crackling. It does not always appear immediately after 
injury. It may be made to increase by sneezing and forcible breathing 
efforts; the location of the primary swelling is generally indicative of 
the source of the air. 

Involvement of cranial nerves may be the result of fractures of 
the base of the skull in which the line of fracture invades the canals 
through which the nerves make their exit from the skull, of laceration 
from a detached fragment of bone or of compression by bone or blood 



166 



TREATISE OX FRACTURES 



clot (Fig. 152). The disturbance of nerve function may be due to 
laceration without fracture, to an injury at the central origin of the 
nerve, or to general intracranial pressure. The involvement of nerves is 
apt to be immediate. A secondary form of paralysis may occur due to 
inflammatory changes, pyogenic in character, along the nerve trunk. 
This may be followed by grave results owing to infection at the base 
of the brain. 

Injuries to nerves are frequently observed to occur in groups : the 
seventh, eighth and sixth; the fifth and third; the ninth, tenth and 
eleventh. From the character of the paralysis one can frequently deter- 



Fig. 153. 



Fig. 152. 





Fig. 152. — Shows position of cranial nerves and their liability to laceration in various fractures at the 

base of the skull. The numbers are the names of the nerves. 

Fig. 153. — Cerebral pressure from an extradural clot from hemorrhage from the posterior branch of the 

middle meningeal artery. (After Rawling.) 



mine the situation of the fracture. The facial and the abducens nerves 
are most frequently involved in fractures of the base. 

Fractures of the anterior fossa may involve the olfactory nerve, as 
in fracture of the cribriform plate of the ethmoid. Disturbance of the 
optic nerve function is generally due to compression or crushing of nerves 
by a displaced clinoid process, rarely by fracture through the optic fora- 
men, and occasionally by hemorrhage into sheath of nerve. Cullen re- 
ports iy cases of compression of optic nerve from fragments near the 
optic foramen ; Holder reports fracture of bones forming the foramen 
in 53 of 86 cases of fracture in this region. Involvement of the ophthal- 
mic division of the trifacial generally is the result of hemorrhage into 
sheath of nerve; of the nasal nerve suggests fracture of the cribriform 
plate; of the supratrochlear and supraorbital branches indicates fracture 
of vertical plate of frontal bone. The oculomotor and trochlear nerves 
are rarelv injured, but mav be affected through hemorrhagic extravasa- 



FRACTUBES OF THE CKANIUM 16T 

tion. Fracture of the middle fossa may involve the maxillary and man- 
dibular divisions of the trifacial but is very rarely seen, requiring fracture 
of the walls of the foramen ovale and foramen rotundum. Involvement 
of the abducens points to fracture of the dorsum ephippii or to hemor- 
rhagic infiltration of nerve sheaths. Schroder observed 58 cases of 
abducens paralysis in fracture of the base, 48 immediately following the 
injury. Irritation, paresis or palsy of the facial suggests fracture of 
petrous bone at the external or internal auditory meatus. When a nerve 
is cut across in the region of the ganglion the paralysis is permanent : in 
hemorrhagic infiltration of nerve sheaths, paralysis is not permanent. 
Involvement of the auditory occurs in fracture of the petrous bone ex- 
tending from the internal ear through the labyrinth, tympanic cavity and 
roof of the auditory canal. It is generally accompanied by paralysis of 
the facial nerve and the lesion is permanent. Kohler observed paralysis 
of the facial nerve 22 times in 48 cases of fracture of the base of the 
skull. Anna Heer records paralysis of the facial nerve 10 times in 11 
cases of injury of cranial nerves, and paralysis of the acoustic nerve 9 
times in 58 cases of fracture of the base of the skull. 

Fractures of the posterior fossa may involve the facial and auditory 
nerve by fracture of the outer angle of the jugular foramen and petrous 
bone. The glossopharyngeal, pneumo gastric, and spinal accessory nerves 
are seldom injured on account of the rarity of fracture at the jugular 
foramen and of the protection afforded by their dural sheaths. Intra- 
cranial injury to these nerves is either by bullets or by fracture of the 
jugular foramen. The hypoglossal is rarely injured intracranially. A 
case is reported by Stierlein of paralysis of the hypoglossal with the 
pneumogastric nerve ; and a case is recorded by von Bergmann of paralysis 
of the hypoglossal with the spinal accessory nerve. 

Intracranial Hemorrhage. — Intracranial hemorrhage may arise from 
injury to the following vessels : the middle meningeal artery and its 
accompanying veins ; the internal carotid artery ; the sinuses of the brain, 
the principal of which are the superior longitudinal, the lateral, the 
transverse, the cavernous and the torcular Herophili, and the pia 
arachnoid vessels. 

Injury to the middle meningeal artery may be produced by penetrat- 
ing wounds, by depressed fractures of the cranium, by fractures extend- 
ing from the base, and as a result of the various traumatisms which 
produce fracture of the skull. It occurs most frequently in conjunction 
with comminuted fractures of the temporal region. Cases have been 
reported in which an apparently trivial blow has resulted in laceration 
of the artery without injury to the bone. 

From the injury to the artery hemorrhage takes place, and ma}* be 
extradural (Fig. 153), subdural or both. As a rule the bleeding is 
extradural ; but when the dura is torn, the extravasation may occur in 
both places at the same time. The blood escapes under a pressure of 80 to 



1(38 



TEEATISE OX FRACTURES 



ioo mm. of mercury, and hemorrhage continues until the extravasation 
produces such intracranial pressure that the blood-pressure is equalized, 
until a thrombus forms, or until death occurs from cerebral compression. 
The extravasation may amount to from 4 to 8 ounces. Kronlein divides 
the resulting hematomas into diffused and circumscribed. The former 
may extend over one-half of the brain; the latter is subdivided into three 
varieties dependent upon the part of the artery injured (Fig. 154): 
anterior haematoma (" frontotemporal "), middle hematoma (" tempero- 
parietal"), and posterior haematoma (" parietooccipital" ). The an- 



v v 




Fig. 154. — Kronlein's method for points of election for trephining in meningeal 
hemorrhage. The three usual areas of extravasation of blood are shown i, ii, iii. 
S-0, supraorbital line; S—A, auriculo-orbital line; V—R, vertical retromastoid 
line; V'-A, vertical auricular line; V"—2, vertical zygomatic line. The large 
circles show the points at which trephining should be performed to ligate the 
anterior and the posterior branches of the middle meningeal artery. 



terior is due to rupture of the anterior division of the anterior branch of 
the artery and is very rare, the middle is due to rupture of the trunk or 
both principal branches of the artery and is most common, and the pos- 
terior is due to rupture of the posterior principal branch of the artery 
and is very rare. Rawling states that hemorrhage from the middle 
meningeal artery was found in 20 per cent, of all the cases of fracture 
of the skull studied, and that in 45 per cent, of the cases the middle fossa 
was involved. D wight found in 149 cases of fracture of the skull ob- 
served at autopsy that there was middle meningeal hemorrhage in 49 



FRACTURES OF THE CRANIUM 169 

cases (29 per cent.), while Nichols reported the same condition in 11 
cases out of 32 autopsies of fracture of the skull (34 per cent.). 

The diagnosis of hemorrhage depends in a great measure upon 
whether there is an external exit to the bleeding. If this exists the 
diagnosis may readily be made. When, however, there is no external 
bleeding, there are cardinal symptoms on which our diagnosis may 
be based. 

A Free Interval. — The interval between the time of injury and the 
onset of symptoms varies. It depends upon the extent of injury, the 
size of the vessel, the presence or absence of a depressed fracture of the 
vault, and the extent and severity of the cerebral concussion with its 
period of unconsciousness. There is, however, as a general rule a lucid 
interval following a primary period of unconsciousness before the uncon- 
sciousness of compression occurs. 

Changes in the Pulse. — Of great importance is the gradual change 
in the character and rate of the pulse. At first there is an increase of 
tension with slowing of the pulse-rate due to intracranial pressure, the 
vagus centre in the medulla being stimulated, so that the pulse may go 
as low as 30 to 40 per minute and th<^ blood-pressure rise, reaching 200 
to 250 mm. of mercury. Later, from long-continued and increasing 
pressure, the vagus centre becomes exhausted and the pulse changes 
markedly in character, the blood-pressure drops, the pulse becomes irregu- 
lar and rapid, and may reach 180 per minute. 

Respiratory Changes. — These consist in changes from the superficial 
respiration or cerebral concussion to the slow, labored, stertorous breath- 
ing of cerebral compression. This is due to pressure upon the respiratory 
centre in the medulla. Later the breathing becomes Cheyne-Stokes in 
character. Hemiplegia is dependent upon areas of pressure over the 
centres of the brain, innervating the parts affected. The extent, character 
and part affected are entirely dependent upon the location, degree of 
hemorrhage, and region affected. The resulting symptoms of pressure 
may consist in twitchings, convulsions, spasticity, or paralysis of the 
muscles of the face, and of the upper and lower extremities of the side 
opposite to the lesion. For the various theories of collateral hemiplegia 
one should read the works of Jedderhouse, Oppenheim, and Artner. 

Eye Changes. — Experimental compression has shown that at the 
beginning of pressure the pupil of the side affected is contracted, that 
with increase of pressure and during the stage of coma the pupils are 
dilated, the pupil of the side affected being greatly dilated and immobile. 
Von Bergmann found in 70 cases of rupture of the middle meningeal 
artery with pupillary changes, that both pupils were widely dilated in 
39 cases, both were markedly contracted in 7, there was dilatation of 
the pupil of the same side as the hemorrhage in 20, and dilatation of 
the pupil of the opposite side in 4. Gubler coincides with the same con- 
clusions. Rawling, in a. study of his cases, found that the pupils were 



170 TREATISE OX FRACTURES 

•equal in 46 per cent, of cases, that the pupils were contracted on the 
affected side in 36 per cent, of cases, and that they were dilated on the 
affected side in 18 per cent, of cases. He considers that the alterations 
in the size of the pupil are of doubtful significance in the diagnosis of 
hemorrhage from the middle meningeal artery, and that the so-called 
Hutchinson pupil, the pupil on the affected side being dilated, due to 
direct compression of the third nerve from extravasated blood, is rarely 
observed. Ophthalmoscopic examination showed, as a rule, the presence 
of oedema of the disk, and dilatation of the retinal veins with contrac- 
tion of the arteries. 

Hemorrhages from the intracranial sinuses are usually the result of 
penetrating wounds, or are due to extensive fracture with comminution. 
The hemorrhage may take place from the superior longitudinal or lateral 
sinus or the torcular Herophili at the vault, and at the base from the 
cavernous sinus. The hemorrhage diffuses rapidly throughout the sub- 
dural space, but the symptoms of such venous bleeding with compression 
are not as definite as in compression resulting from middle meningeal 
hemorrhage. In the latter, symptoms of rapid compression are evident: 
these point to the nature of the lesion when associated with a proper site 
and nature of the traumatism, and with the character of external bleeding, 
if any, especially if blood-corpuscles be present in the cerebrospinal fluid 
obtained by lumbar puncture. 

Proarachnoid hemorrhage is more localized than that observed in 
lacerations of intracranial sinuses, which is generally diffuse subdural 
extravasation. A localized form of subdural hemorrhage, or hsemato- 
cele, is the result of bleeding from torn proarachnoid vessels, due to local- 
ized laceration and contusion of the cortex. The vascular injury, while 
not severe enough to lead to direct symptoms of compression, causes 
vague, indefinite symptoms such as photophobia, headache, insomnia, 
irritability, and slight temperature changes ; later, after a lucid interval 
of from a week to a month, symptoms of compression may occur. If the 
lesion involves the frontoparietal region, aphasia, nervous irritability, 
paralysis of the face, arm or leg centres may develop, and later, as the 
hemorrhage increases and cerebral compression becomes greater, paralysis 
and coma may result. This is a very important form of intracranial 
hemorrhage, and one that is not recognized as often as it should be. 
Patients with such head injury often present signs of cerebral irritation, 
which does not progress for a week or more, and after observation for 
that period they are- considered convalescent. Shortly afterward, how- 
ever, death may occur from an increase in the size of the hemorrhage and 
the resultant compression. 

Intracranial hemorrhage from the internal carotid artery is very 
rare. This artery may, however, be ruptured in severe fractures of 
the middle fossa, from penetrating wounds of the skull, and bullet wounds. 
The rarity of intracranial injury of the cerebral portion of the carotid 



FEACTUEES OF THE CEANIUM 171 

is possibly due to the amount of freedom of motion which is permitted it. 
When complete laceration of the artery occurs, the resulting hemorrhage 
is so severe that death is almost instantaneous on account of the accom- 
panying lesions of the bone and the facility with which external bleeding 
occurs. In two cases reported by Rawling, death was instantaneous, while 
Marchant reports a case of a man injured by a sabre blow who lived 
sixteen days. 

Injury to the Brain. — The most important complications of fracture 
of the skull are injuries to the brain itself. While all fractures of the 
skull are not accompanied by injury to the brain, and severe injury may 
exist without fracture, it can be well understood that severe fractures 
of the skull are generally accompanied by considerable cerebral injury. 
The various lesions affecting the brain are concussion, contusions, cerebral 
irritation, and compression. Of the above complications of fracture of 
the skull, compression due to hemorrhage and to depresed fracture have 
been considered. Concussion and contusion will be briefly alluded to, but 
for a more detailed consideration the reader is referred to special works 
dealing with these conditions. 

Cerebral Concussion. — Many theories have been advanced to account 
for a train of cerebral symptoms, of which the chief one may be said to 
be a primary period of unconsciousness, which is generally designated 
as cerebral concussion. This may be described as an acute cerebral 
anaemia and sudden inhibition of the vasomoter centre leading to a suddden 
fall in blood-pressure. That concussion in this mild degree may exist 
without subcortical lesion or laceration of brain tissue or blood-vessels 
is evident, and that in some cases a fatal result may ensue from this alone 
is evident from the reports of autopsies at which no demonstrable lesion, 
microscopic or macroscopic, could be detected. Other cases may show 
focal areas of hemorrhage and contusion. As a result of the varying 
theories as to the pathological change present in this condition, two schools 
have been established : 

I. That concussion may exist without extravasation or laceration of 
brain tissue (von Bergmann) ; II, that concussion is represented patho- 
logically by a condition of minute contusions scattered throughout the 
brain tissue and that molecular changes take place in the nerve cells 
(Kocher). Concussion without damage to the brain tissue is so unlikely 
that the misleading term should be dropped from surgical nomenclature. 
Its use leads to dilatory surgery. Diagnosis between so-called concussion 
and slight contusion or laceration is clinically impossible. The term con- 
cussion has no real value in clinical surgery. 

Symptoms of Concussion. — Sudden loss of consciousness accom- 
panied by a fall of blood-pressure, subnormal temperature, general pallor, 
and moisture of the skin follow the receipt of the trauma. This state 
is followed by a stage of reaction, in which consciousness returns, the 
temperature rises, the face and the skin generally become hot, moist and 



172 TBEATISE OX FEACTUEES 

suffused, the blood-pressure rises, and there results headache, restlessness, 
and even delirium. In the more severe cases the period of unconscious- 
ness may be prolonged and the patient pass into a state of coma with all 
the evidences of severe intracranial pressure due to cerebral cedema. In 
the latter class the extracranial vessels are dilated, there is marked increase 
of cerebrospinal fluid and generalized cerebral cedema, more marked at 
the base. Rawling refers to a fatal case of concussion in which at opera- 
tion the surface of the cortex was obscured by an ©edematous pia-arach- 
noid one-quarter of an inch in depth. In the mild cases of concussion 
the pupils are equal in reaction to light, the patient may be aroused by 
supraorbital pressure, the pulse is rapid (no— 120), the blood-pressure 
lowered, and the temperature subnormal. There may be temporary loss 
of control of bladder and rectum, but the superficial and deep reflexes 
are not abolished. With reaction the patient slowly returns to con- 
sciousness, the pulse decreases in rate, the blood-pressure increases, the 
pupillary reflexes return, vomiting may take place, the temperature may 
go above normal ; and there is a period of headache and symptoms point- 
ing generally to increased intracranial tension, the result, in all proba- 
bility, of cerebral cedema. 

The Relationship of Temperature Changes to Head Injuries. — This 
subject has been of great interest for many years and many facts have 
been gathered on the subject by Broca, Banti, Guyon, Wolsham, Rawling, 
and others. The most important facts have been deduced by Rawling 
from the observation of over 300 head cases in which accurate records of 
temperature were made and the patients carefully observed during their 
illness. He presents the following deductions : 

"'(1) That, for a variable period of time after the injury, the tem- 
perature is always subnormal — sometimes so low that it cannot be regis- 
tered. This is the period of shock. 

"(2) That the patient may die in this state of shock, but that, if he 
lives, reaction takes place and the temperature rises. 

"(3) That this rise in temperature is, in fatal cases, rapid and pro- 
gressive. In. one case the temperature rose 6~ in seven hours, in another 
8° in four hours. Death occurs when the temperature is at its highest. 
The thermometer may register as high as 106 , and even more when 
taken in the rectum. 

"(4) That the temperature may rise to a moderate height, and there 
becomes stationary. This is the crisis of the case. A subsequent fall in 
temperature generally indicates recovery, a further rise usually points 
to a fatal termination. 

"(5) That the rise of temperature is independent of any special 
osseous lesion, since similar changes are observed in fractures of the 
vault and in fractures of the base. 

"(6) That lacerations of the brain are present in the majority of 
cases in which marked temperature changes are observed, but that the 



FRACTUEES OF THE CEANIUM 173 

changes in temperature are totally independent of any special regional 
brain injury." 

Cerebral contusion is the result of external violence applied to the 
skull and transmitted by the latter, producing varying degrees of injury 
to the brain substance, from mere bruising to laceration, and showing 
clinically all the evidences of cerebral irritation. The injury may consist 
of laceration of the pia-arachnoid vessels, or of minute bruises, diffuse 
lacerations, or even macroscopic destruction of brain tissue. There may 
be only small areas of hemorrhage, but the injury may involve areas of 
the brain the size of an Qgg, or include one or more lobes. Contusions 
are most apt to involve the cortex, and that of the base more often than 
that of the vault. The pons, crura cerebri, cerebellum, and medulla are 
rarelv involved. The most' frequent sites of injury are the frontal and 
the temporosphenoidal regions. Kronlein considers that the accompany- 
ing contusion of the brain generally is due to the inflicting force and is 
most severe at the poles of the line of force. Hence it happens that in 
longitudinal fractures of the base the frontal lobe of the cerebrum and 
the lobes of the cerebellum are injured; in transverse fractures the two 
temporal lobes are contused; and in oblique breaks the frontal lobe of one 
hemisphere and the parietal lobe of the other hemisphere suffer damage. 
Deviations from this rule are due to the irregularities of the cranial base 
and of the brain substance itself. In localized comminuted fractures of 
the vault, the contused area is immediately beneath the area involved. 
Multiplicity of lesions are explained by the semifluid brain consistency 
and known hydrodynamic laws. In addition to the injury of the brain 
itself there is frequently laceration of the meninges with hemorrhage 
into, between, or outside the brain membranes. Hemorrhage may be 
supradural, subarachnoid, or subpial, depending upon the meninges lacer- 
ated and the degree and extent of laceration of the meningeal mem- 
brane's vessels. 

Symptoms of Contusion. — Very frequently contusion of the brain 
is accompanied by symptoms of concussion and followed by those of 
compression so that perfect differentiation is impossible. Often the 
lesions are multiple and the clinical picture becomes obscure, because 
the symptoms of contusion indefinitely merge into those of compression 
from the accompanying hemorrhage. On the other hand, there may be 
rather extensive lesions of the brain tissue and injury to the meninges 
without any definite localizing symptoms. Again, the symptoms of 
cerebral contusion may be similar to those of a purulent encephalitis 
of meningitis. 

As a rule there is an initial stage of unconsciousness due to concussion, 
which may rapidly pass and give place to symptoms of cerebral irritation. 
The chief symptoms of the latter condition are a rapid increase of blood- 
pressure, shown by high tension, fairly rapid pulse, marked mental irri- 
tation, and occasionally violence requiring restraint. The patient resists 



174 



TREATISE OX FEACTTKES 



efforts to draw open the eyes, pupillary and retinal examinations are im- 
possible, headache is severe, restlessness is extreme, he generally lies on 
his side with legs drawn up, there may be involuntary passage of urine 
and faeces, the temperature is above normal, and the skin is hot and dry. 
Lumbar puncture generally shows blood in the cerebrospinal fluid. The 
symptoms of contusion are very pronounced, convalescence is prolonged, 
and patients complain for a long time of headache, mental irritability, and 

at times of depression. The men- 
tal character may alter and the 
end result may be traumatic neu- 
rasthenia, traumatic cephalalgia, 
or epilepsy. 

The primary state of con- 
tusion may be followed by that of 
compression — acute when due to 
rapid hemorrhage, delayed when 
due to slow hemorrhage, to 
abscess, to subdural hsematocele, 
or to tumor formation. 

Diagnosis cf Fracture of the 
S k u 1 1. — Fractures of the 
Vault. — In closed depressed 
fractures of the vault the diag- 
nosis may be made from the char- 
acter of the depression felt by 
palpation, the nature of the in- 
jury, and the symptoms of intra- 
cranial complication. Linear 
fractures may at times be recog- 
nized by the tenderness over the 
line of fracture or, as suggested 
by von Bergmann, by the changed 
percussion note, if there is any 
gaping of the fissures. Differen- 
tiation of depressed fracture from 
subaponeurotic extravasation should be carefully made by the peculiar 
feel to infiltrated area of the latter, which may be indented with moderate 
pressure. In open fractures, depressed and comminuted conditions may 
readily be recognized. Linear fractures may be diagnosed by oozing, which 
may be seen issuing between the walls of the fissure, by the slight uneven- 
ness of their edges, and by the presence of a fissure not at the site of 
a suture. 

Fractures at the Base. — In fractures involving the base of the 
skull the diagnosis is made more from the symptoms of the injury to 
the intracranial contents than upon any possible evidence obtained by 




Fig. 155. — Hsematoma of scalp without fracture. 



FBACTUBES OF THE CBAXIUM 



175 



observation of the fracture itself. Fractures of the base are determined 
by the evidences of hemorrhage, intra- and extracranial, the escape of 
cerebrospinal fluid, the escape of brain matter, localized or diffuse emphy- 
sema due to rupture of the air-containing sinuses, the involvement of 
cranial nerves, the development of cerebral oedema, purulent encephalitis 
and meningitis, the presence of blood in the cerebrospinal fluid obtained 
by lumbar puncture, and by the complicating symptoms of cere- 
bral concussion, contusion, or compression. Radiography may be of 
extreme value, and a study of X-ray plates taken in two planes should 
be a routine practice in doubtful cases when possible. 



st — olfactory 



i t j ^_-- 2nd — oplic 

if! _^ 3rd— oculomotor 



Cavernous sinus 



Circular sinus 



Superior petrosal sinus 
Inferior petrosal sinus 



Sigmoid sinus 



Occipital sinus 



Transverse or lateral sinus 




4th— trochlear (pathetic 



5th— trigeminal (trifacial) 
6th — abducent 



— 7th — facial 

8th— auditory 
I— 9th— glossopharyngeal 
r-yi — 10th — vagus (pneumogastric) 
th — spinal accessary 

12th — hypoglossal 



Superior longitudinal sinus ^^ 

Fig. 156. — Interior of cranium and nerves (Davis). 



Differential Diagnosis of Coma Due to Head Injury from Other 
Forms of Unconsciousness. — While it may be possible to readily diag- 
nose traumatic coma from a history of the accident and the various evi- 
dences of injury present, the surgeon at times is unable to obtain any 
history or to notice at first glance evidence of injury. In these cases 
the coma due to concussion, contusion, and compression should be differ- 
entiated from that which, occurs in alcoholism, in apoplexy, in opium 
poisoning, in uraemia, in epilepsy, and in diabetes. A correct diagnosis 
in many cases can be made only after a thorough examination of the 
patient. This examination should begin at the head and include the 
entire body. In fracture of the skull there may be evidence of external 
injury to the vault, in the frontal, temporoparietal, or occipital regions, 



176 TREATISE OX FRACTURES 

or at the level of the base of the brain. Bleeding from the nose, mouth, 
or ears, or the escape of cerebrospinal fluid or brain tissue will clear up 
the diagnosis. The presence of blood in the cerebrospinal fluid obtained 
by lumbar puncture is also suggestive of fracture at the base combined 
with intracranial hemorrhage. Palsies from intracranial injury to nerves 
are suggestive of fracture at the base. There may, of course, be prior 
disease of the viscera, leading to unconsciousness, in addition to the injury 
which is suspected to be its cause. Lumbar puncture should not be reck- 
lessly employed. 

The presence of old scars or fresh injuries to the tongue is sug- 
gestive of epilepsy. In uraemia there is a sweetish odor to the breath, in 
diabetes the odor is typical of acetone, and in alcoholism the peculiar 
stale odor of liquor is noticeable. In apoplexy, compression, and trauma 
there may be facial palsies. In opium poisoning, diabetes and concussion 
the face is pale, peaceful, and the breathing quiet. In compression, apo- 
plexy, uraemia and alcoholism the face is congested and the breathing 
is stertorous. In apoplexy and injury there may be unilateral paralysis 
of the extremities, limited to upper or lower or both, combined with exag- 
gerated reflexes, while in alcoholism resistance to movement is marked. 
Convulsions suggest uraemia, epilepsy, or injury. Examination of the 
urine with the presence of albuminuria and casts points to uraemia, while 
in diabetes the urine contains sugar and possibly acetone, diacetic and 
/?-oxybutric acids. Examination of the eyes is very important. The 
presence of paralysis of ocular muscles points to injury or apoplexy, 
while the presence of subconjunctival and palpebral hemorrhage points 
to injury. In uncomplicated fractures of the base there are no pupillary 
or disk changes. When accompanied by concussion the pupils are equal, 
dilated, and react to light ; in contusion the pupils may be unequal, dilated, 
or contracted, and generally fail to react to light ; but in cerebral com- 
pression they may be equal or unequal, dilated, and do not react to light. 
In apoplexy the pupils are generally unequal, dilated, and do not react to 
light, and in hemorrhage into the pons the pupils are pin-pointed. In 
diabetes and epilepsy the pupils are equal, sluggish, and react to light. 
In opium poisoning the pupils are contracted, equal, and do not react 
to light. In uraemia the pupils are dilated and react to light slowly. In 
alcoholism the pupils are generally normal; but in extreme stages of alco- 
holism they are usually dilated and fail to react to light. Examination 
of the fundus in these varying conditions may show distinctive changes, 
such as retinal hemorrhage in trauma and in arteriosclerosis, the charac- 
teristics of optic neuritis in uraemia and diabetes, and choked disk in 
pressure from cerebral abscess or intracranial hemorrhage or tumor. 

Examination of the pulse will give valuable information. The pres- 
ence of atheromatous arteries will suggest apoplexy; a high tension, slow 
pulse with relatively high blood-pressure, will suggest uraemia, compres- 
sion, and apoplexy. The presence of a very slow full pulse may be indica- 



FRACTURES OF THE CRANIUM 177 

tive of alcoholism, although the pulse in this latter condition is variable. 
In concussion and contusion of the brain the pulse may be rapid, weak, 
and accompanied by low blood-pressure. 

The temperature shows marked variation in these conditions. In 
uraemia, concussion, opium poisoning, and epilepsy the temperature is 
normal or subnormal. In apoplexy, contusion, compression, and alco- 
holism the temperature is generally above normal, while in hemorrhage 
into the pons there is hyperplexia as a rule. 

Prognosis. — Here again the question of results is dependent upon 
the accompanying lesion to the intracranial structures rather than upon 
the degree of injury to the cranial walls. Extensive fracture of the 
cranium unaccompanied by lesion of the intracranial contents may have 
a very favorable prognosis, whereas a small fissured fracture accompany- 
ing a small lesion of the pons or medulla is liable to have a sudden fatal 
termination. The two accompanying conditions most frequently seen in 
fractures of the skull that greatly determine the prognosis are infection 
and hemorrhage. The infections through fracture of the cranium gener- 
ally act through open wounds of the scalp and are usually streptococcic, 
staphylococcic, or tetanic in nature. Infections reaching the cranial con- 
tents may gain entrance through the accessory sinuses of the nose, the 
nasopharynx or external auditory meatus, and are often pneumococcic in 
character. Fractures of the base are liable to more serious complications 
than fractures at the vault, on account of the nature of the violence causing 
basal fractures, the mechanism of their production, and the greater liabil- 
ity to injury of the important structures situated at the base of the brain. 
Among secondary complications may be mentioned meningitis, abscess, 
and localized hematoma. An injury apparently insignificant may prove 
to be fatal on account of the resulting meningitis or abscess. 

Hemorrhage is probably the most important complication of fractures. 
As stated above, this may be small in amount, but if it takes place in the 
pons or medulla death occurs very rapidly. In other cases the hemor- 
rhage may be progressive, until symptoms of compression arise, and be 
followed by death unless operative relief is given. Intracranial hemor- 
rhage taking place in the presence of laceration of the dura with free exit 
from the brain-case to the outside does not, as a rule, produce death 
from pressure of the bleeding. Minute hemorrhages accompanied by 
marked oedema may cause compression, coma, and death. 

In depressed, comminuted fractures of the vault death may occur on 
account of compression due to depression of fragments and hemorrhage ; 
depressed fragments may be present and cause no symptoms at all. 

Battle, from a study of 168 cases of fracture of the cranium, places 
the mortality at 32 per cent. Crandon and Wilson, from a series of 
530 cases, give a mortality of 44 per cent. Rawling states that of those 
fractures purely or mainly basic observed by him, 116 recovered and 89 
died, a mortality of 44 per cent. In a primary fracture of the vault 
12 



ITS 



TREATISE ON FRACTURES 



Rawling gives 



the following statistics based on a study of 88 cases 



observed at St. Bartholomew's Hospital from 1900 to 1906: 



Under the age of five 
Under the age of ten 
Under the age of fifteen 
Under the age of twenty 
Under the age of thirty 
Under the age of forty 
Under the age of fifty 
Under the age of sixty 
Over the" age of sixty 



8 lived and 2 died. 

2 lived and 3 died. 
6 lived and o died. 

10 lived and 3 died. 

9 lived and 1 died. 
16 lived and 9 died. 

3 lived and 7 died. 

2 lived and 1 died. 

3 lived and 3 died. 



Mortality, 20 per cent. 
Mortality, 60 per cent. 
Mortality, o per cent. 
Mortality, 23 per cent. 
Mortality, 10 per cent. 
Mortality, 36 per cent. 
Mortality, 70 per cent. 
Mortality, 33 per cent. 
Mortality, 50 per cent. 



59 lived and 29 died. 



Mortality, 37 per cent. 



The mortality also varies according to the fossa involved in fractures 
of the base of the skull. Rawling considered that fracture of the middle 
fossa presents the greatest dangers. This fossa is involved with great 
frequency in fractures of the base; and the injuries are dangerous on 
account of the avenues of possible infection leading into it from the 
nasopharynx and the ear. The hemorrhages which may occur in frac- 
ture involving this fossa are from the middle meningeal and internal 
carotid arteries and cavernous sinus, and are always grave. Leonard 
Hill, however, considers that involvement of the posterior fossa is the 
most dangerous on account of the fact that the main vital centres are 
situated in the region of the fourth ventricle and that any increase in 
intracranial pressure exerts its effect most rapidly when the lesion is 
situated beneath the tentorium cerebelli. 

Burkhard records 42 recoveries in 43 cases of uncomplicated fractures 
of the skull, and Wagner records only two deaths among 83 recent 
compound fractures of the skull. Von Bergmann considers that patients 
suffering with fracture of the skull who are not killed instantly are in 
the greatest degree of danger during the first twenty-four to forty-eight 
hours. Wagner records 23 cases surviving this period in which only 
one death occurred. 

In regard to prognosis, Rawling considers that all cases of head injury 
may be grouped into four classes, dependent upon the temperature changes 
as follows : 

" Group 1. The temperature, at first subnormal, undergoes a rapid 
and progressive rise. Prognosis most unfavorable. 

" Group 2. The temperature, at first subnormal, rises gradually to 
101 or 102 ° and there 'marks time.' This hesitancy marks the crisis 
of the case, further elevation indicating a fatal result, whilst a fall offers 
every hope of recovery. 

" Group 3. The temperature, at first subnormal, rises to normal and 
remains at that level. Prognosis very favorable. 

" Group 4. The temperature, at first subnormal, remains subnormal. 
The condition of shock persists, and the prognosis is most unfavorable." 



FRACTURES OF THE CRANIUM 179 

Xot only does Rawling consider the temperature chart as of invaluable 
help in the prognosis, but it is also a guide in the treatment of the case. 
This will be referred to later under treatment. 

Eguchi states that from 1.3 to 4.7 per cent, of all skull injuries 
admitted to the reserve hospitals of Japan during the Russo-Japanese 
War were followed by traumatic epilepsy. In these, injuries to the 
bone and dura mater produced irritation of the brain. The shortest 
period from the day of injury to the beginning of the epilepsy was 3 
days; the longest was 442 days, the average 161 days. Operation gave 
good results in Eguchi's cases. A cure was obtained in 11 cases, or 
90.9 per cent., and no results in 1 case, or 9.1 per cent. Death followed 
operation in this case from the rupture of an aneurism. 

A. C. Burnham reports the following statistics based upon the obser- 
vation of thirty-five cases of compound fractures of the base of the 
skull treated at the Presbyterian Hospital, New York. Cases which 
were surely basal fractures, but in which there was some doubt as to the 
diagnosis of compound fracture, were not included in this report. Of 
these 35 patients 14 died and 21 recovered, a general mortality of 40 per 
cent. Six patients died during the first forty-eight hours, all in pri- 
mary shock as a result of the injury. Eight patients died after 
the third and before the fourteenth day, after having partially or 
wholly recovered from the initial shock of the accident. Of these 8 
patients 5 died of meningitis. The causes of death and the day on which 
it occurred in the fatal cases are as follows : 5 died of meningitis — on the 
fourth 2, on the sixth 2, and 1 on the thirteenth day, respectively. Two 
patients died of bronchopneumonia on the fourth day. One patient died 
on the tenth day after secondary hemorrhage and operation. It can 
readily be seen from the above figures that even in those patients sur- 
viving from the initial shock following compound fracture of the base 
of the skull the .mortality (in this series 25.5 per cent.) is high. 

Treatment. — The treatment of fractures of the cranium varies with 
the site of the fracture and its character. That proper for lesions of the 
vault of the cranium may greatly differ from that needed in fractures 
of the base. The line of treatment depends upon whether the break in 
the bone is closed or open ; depressed, comminuted, fissured, or punctured ; 
associated with concussion, contusion, hemorrhage or oedema, or free 
from these intracranial complications. Whether it is open to infection 
from the skin surface or through the nose, pharynx, or ear, is of great 
importance. When the fracture is of the vault or base and unaccom- 
panied by any intracranial lesions, the rules of treatment are very simple. 
When complications exist the treatment depends upon the character, 
severity, and degree of injury to intracranial contents and the avenues 
of possible infection. In fracture of the vault the indications for opera- 
tive intervention are usually distinct and clear-cut. It is generally per- 
formed for depression of fragment or hemorrhage from the middle menin- 



180 



TEEATISE OX FBACTTJRES 



geal artery or longitudinal sinus. In fractures of the base the indications 
for operation are not dependent so much upon the injury to the cranium 
itself, but rather upon critical intracranial complications. 

General Lines of Treatment. — In all closed fractures of the vault 
or base one should adopt some rational form of general treatment. 
Operation should only be considered when there is some well-defined 
indication for the operative procedure or a degree of uncertainty making 
exploratory incision wise. Then it should be performed with the hope 
of giving the patient a chance for immediate recovery or as a means of 



Ethmoidal spine 



Crista gall 



Olivary emi 
nence 



Ant. clinoid 
process 



Post, clinoid 
process 




Hiatus Fallopii 



Post lacerated or 
jugular foramen 



Sphenoidal fissure 
(concealed) 



Foramen rotundum 



Foramen ovale 



Inf. petrosal sinus 
Basilar groove 



Sup. petrosal sinus 
Lateral sinus 



Post condy- 
loid foramen 



Lateral sinus Torcular Herophili 

Base of skull from above. 
Fig. 157. — Interior of base of cranium cavity in the skeleton itself. 

preventing remote effects of head injuries, such as a traumatic neuras- 
thenia, chronic cephalalgia, and epilepsy. 

The surgeon should be guided by the general condition of the patient, 
the character of the injury, the location of the fracture, the presence or 
absence of intracranial complications, the blood-pressure, the character 
of the pulse, the respiration, and the degree and depth of coma present. 

The patient should be placed in bed, in a room alone if possible; 
and have a competent and intelligent attendant to record the temperature, 
pulse and respiration every hour, to observe changes in the patient's 
condition, and to note the development of consciousness, coma, convul- 
sions, paralyses, etc. The head should be shaved, an ice-cap applied 
and the patient given a cathartic, if possible; if he is unconscious, the 




FBACTUBES OF THE CRANIUM 181 

lower bowel should be emptied by a, cleansing enema, and the bladder 
evacuated by catheter. In cases in which there is a possibility of infection 
of the meninges occurring, the patient should be given 10-20 grains of 
hexamethylenamine three times a day. This drug should be continued 
for a period of three to four weeks, or until all danger of meningeal infec- 
tion has passed. This medication follows the advice of Crowe and 
Gushing as a prophylactic measure against the development of infection 
of the meninges. They believe that hexamethylenamine given by the 
mouth appears in the cerebrospinal fluid in from thirty minutes to one 
hour after ingestion of the drug, and that its 
use exercises a decidedly inhibitory effect on 
the development and extension of menin- 
geal infections. 

When the temperature remains subnor- 
mal for a time, the patient should lie with 
the head low and be surrounded with hot- 
water bottles and covered with blankets. In 
severe cases of shock, with subnormal tem- 
perature and low blood-pressure, it may be 
advisable to bandage the extremities and 
overcome the vasomotor depression by fig.i S 8.— Repair by fibrous tissue after 
hypodermic injection of atropin, 1/100 trephining. 

grain; by the intravenous injection of normal saline solution, or by 
stimulating enemata such as the following : salt solution 2 ounces, black 
coffee 2 ounces, brandy 1 ounce, tincture of digitalis 1 drachm, to be 
repeated in two hours if necessary. This treatment is advisable only in 
those extreme cases in which marked shock is present, because there is 
considerable risk in overstimulation should there be laceration of intra- 
cranial vessels. It must be remembered, however, that patients in marked 
shock will die, and. that very quickly, unless stimulated. 

In cases where the shock has been overcome and there is a progressive 
rise in temperature, and in those in which there is a progressive rise in 
temperature from the beginning, not due to active stimulation, and in 
which all the symptoms point to compression without any localizing 
signs, the treatment should be entirely different. Then, instead of stimu- 
lating the patient, the surgeon's efforts should be directed toward reducing 
intracranial pressure. There are several ways of reducing this pressure : 
venesection, lumbar puncture, and decompression operations on the skull 
in the cerebellar or intermusculotemporal regions. 

Venesection. — The treatment of intracranial compression due to 
hemorrhage by venesection has advocates and opponents. Its use as a 
means of reducing arterial pressure is therefore not established. Von 
Bergmann, Hill, and Rawling consider that it is of great value, while 
Falkeheim, Naunyn, and Cushing are not in favor of it, except early in 
a very few selected cases, in which there is an abundant reserve on the part 



182 



TREATISE OX FRACTURES 



of the vasomotor centre. Some experience has shown that it has been 
of use when employed in early cases, but that in late cases in which the 
vasomotor centre is exhausted it is useless. The blood may be withdrawn 
from any of the superficial veins of the body, the safest and most readily 
accessible being the median basilic, external jugular, and the long saphe- 
nous veins. About ten to thirty ounces may be withdrawn under aseptic 
precautions. The quantity should be governed by the fall of blood- 
pressure to nearly normal. 

Lumbar Puncture. — xAs a diagnostic procedure, lumbar puncture 
probably has its use; but as a means of relieving intracranial pressure it 

is doubtful whether it does 




good. 



It may lead to danger- 



Fig. 159. 



-Wornian sutures and indentation of punctured 
fracture. (Roberts.) 



ous and fatal results by 
intracranial pressure forcing 
the medulla and the edge of 
the cerebellum into* the fora- 
men magnum, after the sup- 
port of the cerebrospinal 
fluid has been removed by 
lumbar puncture. However, 
the procedure has many ad- 
vocates. Quinn records 
seven cases of fracture of 
the skull " cured " by means of lumbar puncture. In one of the cases the 
procedure was performed eight times. 

Decompression. — Cerebellar decompression is rarely a justifiable 
procedure in cases of diffuse intracranial injuries, and the good results 
to be obtained by this procedure are questionable. The intermusculo- 
temporal decompression operation advised by Gushing has been followed 
by brilliant results, especially in the hands of its originator. The advan- 
tages claimed for this procedure are that it is done in the middle fossa, 
a region where most lesions at the base occur; exposure of the middle 
meningeal artery is obtained and approach to the region occupied by the 
temporosphenoidal lobe, where most frequent contusions of the brain 
occur, is gained ; dependent drainage is obtained with ease, and the drain- 
age so obtained occurs through the split temporal muscle better than 
through the scalp alone. This position, while securing good drainage, is 
not likely to be followed by hernia cerebri. 

Fractures of the Vault. — In closed fissured fractures of the vault 
without intracranial injury the treatment should consist of rest and 
observation. It is difficult to determine, except by X-ray plates, that such 
a fracture is present. Many fractures of the vault are, however, either 
depressed, comminuted or compound, and here the treatment will differ. 
Operative intervention is advisable in all depressed fractures, punctured 
fractures, fractures complicated by intracranial hemorrhage, and as an 



FBACTUKES OF THE CRANIUM 



183 




exploratory measure when the condition of the bone is uncertain. Frac- 
tures associated with only a mild degree of concussion require no active 
treatment beyond rest in bed and treating the symptoms of concussion as 
they arise, unless there is reason, from the character of the trauma, to 
think that the inner table may be splintered. When there is a marked 
degree of concussion present, more active measures are required. With 
subnormal temperature, stimulation is indicated until reaction occurs. 
When the injury is associated with suspected cerebral contusion, the 
patient should be kept in a darkened room, and sedatives are required ; 
in addition, some moderate form of restraint may be wise. It is wise to 
shave the entire scalp, in 
order that irregularities in 
the contour of the bone, 
small wounds or contusions 
of the integument, and sec- 
ondary extravasations of 
blood into the soft tissues 
may not exist unobserved. 
An ice-cap should be ap- 
plied to the head, and mor- 
phine and atropine are 
indicated until the restless- 
ness disappears. As cere- 
bral contusion is associated 
with more or less laceration 

of the brain substance, the patient should be under a long period of obser- 
vation and restrained from too great activity, physical and mental. 

In depressed or comminuted fracture of the vault, with or without 
symptoms of compression and in obscure fissured fracture, operative inter- 
ference is advisable. By this means alone is one able to elevate depressed 
fragments, determine the presence of fracture of the inner table alone, and 
also prevent many of the remote effects of brain injury. Deaths from 
consecutive or associated brain lesions are not uncommon in cranial 
fractures ; but this mortality may be decreased by early resort to intelli- 
gent aseptic operative intervention in appropriate cases. Elevation and 
removal of bone with extraction of splinters of the inner table, removal 
of large clots, and incision even of the dura mater may avail nothing 
when there has been serious contusion or multiple lacerations of the in- 
terior of the brain substance. It is, however, undoubtedly true that 
many patients have died because peripheral lesions subjacent or adjacent 
to the fracture have been unrecognized, and therefore untreated by surgi- 
cal means, until the intracranial pathological process had advanced too 
far to be remediable. 

In many instances, uncertainty as to the existence of fracture or its 
character is more dangerous to the patient's life or future mental integrity 



Fig. 160. — Depression of inner table. (Roberts's Surgery.) 



184 



TREATISE OX FRACTURES 



than the conversion of a closed fracture into an aseptic open fracture or 
the exposure of the brain or its membranes by operative perforation 
of the bony wall of the cranial cavity. Meningitis, with or without cere- 
britis, is frequently caused by infection through the fracture as a point 
of entrance. Irritation from spicules of the inner table or from small 
clots, subcranial or subdural, and compression from large hemorrhages 
within the brain case may be revealed by opening the scalp freely to 
inspect the bone and cutting away bone to permit ocular examination of 
the contents of the cranium. 

Operative Procedures for Fracture of the Vault. — The scalp 

should be shaved, thoroughly 
washed with soap and water, 
alcohol and ether. A rubber 
band or scalp tourniquet is ap- 
plied around the head above the 
ears and a flap raised according 
to the location and extent or 
comminution or depression of 
fragments. The pericranium is 
stripped away from the in- 
volved area. Often it is possible 
with a suitable bone elevator to 
lift up depressed or comminuted 
fragments. If this is not pos- 
sible, a trephine opening may 
be made at the edge of depres- 
sion and the fragments elevated 
after the removal of a button 
of bone. The centre pin of the 

Fig. 161. — Masland saw, flexible cable and electric motor, tj-gnhine should be placed On 
used for resecting cranium through small perforation made r r 

with Roberts's electric trephine. SQ \[^ b 0T1 Q, anc l t he CrOWn of the 

trephine should overlap the margin of the fracture so as to permit the ele- 
vator to be used. The centre pin should be withdrawn after a groove is 
made for the cylindrical edge of the trephine. Exposure of the dura should 
be carefully made, lacerations should be carefully investigated, and exam- 
ination made for the presence of fragments in the brain substance and 
for extra- or subdural hemorrhage. The dura should either be incised 
or the laceration in the dura, if one is present, should be enlarged, when 
the brain is believed to be damaged. Otherwise the dura need not be 
disturbed. Detached bone fragments should not be replaced unless the 
brain is thought to be uninjured and the wound is sterile. After tre- 
phining or other operation on the cranium for fracture, the fragments 
may at times be replaced, if sterile or sterilized, in order to get a bony 
closure of the opening instead of the fibrous or fibrocartilaginous mem- 
brane which otherwise is provided by nature. Sometimes a thin shaving 




FRACTURES OF THE CRANIUM 



185 



of bone may be cut from the margin of the opening and laid over the 
hole like a lid. These methods may be left for a secondary operation if 
postponement is considered wiser than immediate plastic closure. After 
all fragments in the brain substance have been removed and hemorrhage 
controlled, the wound of the dura should be closed with interrupted 
sutures of line catgut, and the skin flap closed with interrupted sutures 
of silkworm gut without drainage. 

The hand trephine is available. Electric saws, like that of Masland, the 
Gigli wire saw, and the craniectomy forceps may be used with advantage, 
if preliminary openings are made with a small trephine or a perforator. 
These methods are of exceeding value when it is desired to raise a trap- 




Fig. 162. — Method of trephining with the Hudson instruments. After exposure of the site of fracture 
the skull may be opened at the site of depression. 

door flap of scalp and bone for inspection of an extended surface of the 
brain. Such an osseo-cutaneous resection permits the hinged flap of 
bone and soft parts to be relaid in its former position after the operation 
is completed. The gnawing forceps is a convenient instrument with 
which to trim away sharp edges of an opening after elevation or removal 
of comminuted fragments ; or to gradually enlarge a trephine opening. 
It is at times necessary to make more than one opening to unlock frag- 
ments. Gutter fractures are difficult to elevate. It is well to make the 
trephine opening at one end of the gutter-like depression at the point 
where the depressed bone begins to dip inward from the solid bone. 
A gnawing forceps, which cuts a narrow channel entirely through the bone, 
should then be run along the margin of the depressed area the entire 
length of the fracture. After this has been done, an elevator used as 



18G 



TREATISE OX FRACTURE: 



a lever under the end of the deep part of the gutter will prise up the two 
sections of driven-in bone. The lateral groove previously cut parallel to 
the line of break permits this. 

In open fractures, the scalp should be shaved, thoroughly scrubbed 
with soap and water, benzine and ether. The edges of the wound should 
then be trimmed with a pair of scissors and the entire wound irrigated 
with a 2 per cent, solution of iodine in alcohol. The wound should then 
be enlarged for inspection of the seat of fracture, and the same general 
lines of treatment followed as in simple fractures. Drainage will de- 
pend upon the character of the wound, the general condition of the patient, 
and the degree of contamination. 

Fractures of the Base of the Skull. — In simple fractures of the base 
of the skull without intracranial complications, the treatment should be 






Fig. 163. 



-Hudson's trephine bits, showing the use of the spiral perforator, the spiral 
follower, and the enlarging burr. (After Rawling.) 



symptomatic. The prognosis and treatment depend entirely upon the 
kind and degree of the accompanying lesions. The same general prin- 
ciples given above should be carried out. Of especial gravity are hemor- 
rhage, with the escape of cerebrospinal fluid or brain tissue from the 
nose, mouth, or ear, the possibility of infection being very great; and 
intracranial hemorrhage producing compression of the brain. In hemor- 
rhage from the nose, mouth, or ears, or when there is discharge of 
cerebrospinal fluid from these orifices, syringing of the nose, mouth, or 
ears is strongly contra-indicated. The nose or ears should be kept clean 
by means of swab of cotton soaked in boric acid solution. Under no con- 
dition should these cavities be packed with gauze ; and syringing is liable 
to force organisms from these cavities to the meninges and thereby pro- 
duce infection. Packing of these orifices is unwise because the escape 
of blood lessens the degree of compression of the brain, especially when 
hemorrhage is profuse, and may thereby be life-saving. 

Intracranial Hemorrhage. — As middle meningeal hemorrhage usually 
produces compression of the brain and unless relieved causes eventually 
coma and death, the expectant form of treatment is hazardous and should 



FRACTURES OF THE CRANIUM 



187 










Fig. 164. — Removing a button of bone at the edge of the depressed fracture with the hand trephine. 
The Roberts aseptic conical trephine and other perforating methods are available. Note use of scalp 

tourniquet. 




-^ 



/ 






fk 



Fig. 165. — Method of elevating depressed fragment of bone after trephine opening has been made. 



188 TKEATISE OX FKACTUKES 

not be followed. So soon as symptoms of this form of hemorrhage are 
presented, immediate operation is indicated. Various methods of ap- 
proach have been suggested. Perhaps the one most universally followed 
is that of Kronlein. The principal thing to be borne in mind is the loca- 
tion of the middle meningeal artery. The main artery runs across the 
middle of the temporal fossa; it divides into its branches at the pterion, 
which is about two fingers' breadth above the zygoma and a thumb's 
breadth behind the vertical (sphenofrontal) process of the malar bone 
(Vogt's rule). Vogt advises placing the point of the trephine at the 
insertion of these two points. Kronlein describes an anterior and a 
posterior point of election for trephining as follows (Fig. 154) : A line 




!*. * 




FlG. 166. — Showing method of exposure of anterior and posterior branches of the middle 
meningeal artery at the points of election. (Modified after Rawling.) 

is drawn through the supraorbital ridge backward, parallel with the 
horizontal line of the skull, which is a line through the external auditory 
opening and inferior orbital ridge. Both points of election for trephin- 
ing should be on this line (Fig. 166), the anterior one 3 or 4 cm. behind 
the zygomatic process of the frontal bone, the posterior one at the inter- 
section of the given line with a vertical line passing immediately behind 
the mastoid process. Circumscribed hsematoma of the fronto-temporal 
and temporoparietal regions may be reached through the anterior open- 
ing and the parieto-occipital variety of blood clot through the posterior 
opening. Krause advises exploration through an osteoplastic flap similar 
to the one he uses for the Gasserian ganglion excision. Cushing recom- 
mends an approach by means of the intermusculotemporal operation. 
Whichever method of approach is used, the opening should be enlarged 



FEACTUEES OF THE CEANIUM 189 

(Fig. 167) with craniectomy forceps, after removing the button of bone, 
until sufficient exposure is obtained. The source of the extravasation can 
readily be determined by removal of the clot with a flat spoon and irri- 
gation of the cavity with salt solution. The bleeding point may be 
secured and the hemorrhage checked by one of the following methods : 
by ligature, on both sides of the bleeding point; by torsion of the vessel; 
bv gauze plugging; by occlusion of the artery by crushing the bony 
groove in which the vessel lies ; by plugging the foramen spinosum with a 
bone or wooden plugs or paraffin; by ligature of the common or external 
carotid arteries. 

Cushing considers that 90 per cent, of cases of meningeal hemor- 



.'* 




Fig. 167. — Showing method of enlarging trephining openings at points of election to 
reach the anterior and posterior branches of the middle meningeal artery. (Modified 

after Rawling.) 

rhage prove fatal, if unrelieved surgically, 60 per cent, of them dying 
within the first twenty-four hours. Of a series of cases operated upon 
67 per cent, recovered. Wiesmann states that of 143 cases treated under 
the expectant treatment, 131 died and 12 recovered. Of 167 fatal cases 
not less than 60, more than one-third, died during the first twenty- 
four hours. 

The cause of death in those dying within twenty-four hours is prob- 
ably paralysis of the heart and respiration from pressure on their centres 
in the medulla. In patients living several days or weeks and then dying, 
the cause of death is probably a generalized oedema. Yon Bergmann 
reports no operative cases with 74 recoveries and 36 deaths, a mortality 
of 32.27 per cent. ; Blake, 42 cases submitted to operation with only 3 
deaths, and Duchain, 2j operative cases with only 6 deaths. 



190 TEEATISE OX FBACTTJBES 

Hemorrhage from rupture of intracranial sinuses demands imme- 
diate operation. As a general rule these injuries are associated with 
either open, depressed, or punctured fractures of the skull, and a diffuse 
subdural hemorrhage results. In such instances, the wound, if the frac- 
ture is compound, should be enlarged under thorough asepsis; and if a 
closed fracture is present the method of procedure should be to expose 
the bone by an incision. Depressed fragments, should be elevated, de- 
tached fragments removed, the opening in the cranium enlarged if neces- 
sary with craniectomy forceps so that sufficient exposure of the involved 
sinus be obtained for working purposes. If possible, the laceration of 
the sinus is to be closed by interrupted sutures of fine silk, or by a lateral 
ligature; or both of the bleeding ends of the sinus should be ligated with 
silk. If this is impossible, the hemorrhage may generally be controlled 
by compressing the sinus with sterile gauze packing; the wound in the 
scalp is to be closed except at the point of drainage. Luys reports 42 




Fig. 168. — Hopkins gnawing forceps. 

cases of injury to the sinuses, of which 20 were followed by good results 
from operative interference. 

Hemorrhage from the cranial portion of the internal carotid artery is 
followed by death so quickly that operative intervention is gener- 
ally impossible. 

In subdural localized hemorrhage, which is generally from injury 
to the pia-arachnoid vessels and laceration of the cortex, the symptoms 
of hemorrhage arid the development of pressure symptoms are delayed 
from several days to a week or more. Upon the development of localizing 
symptoms of pressure, operative interference is demanded. Under asep- 
tic precautions, and with a scalp tourniquet, a flap is raised, the cranium 
trephined, and the dura exposed. The membrane will be found to be 
blue, non-pulsatile, and bulging. The dura should be incised, the clot 
removed with a spoon, and the cavity cleansed by irrigation with warm 
normal salt solution. Afterward the opening in the dura should be closed 
with catgut or silk suture, excepting at the lower portion, where a rubber 
tissue drain should be placed and the scalp wound sutured, except 
at the point of drainage. The drain should be removed at the end of 
forty-eight hours (Figs. 169-172). 

Bowen, to whom we are indebted for a most complete monograph 
on this subject, reports 72 cases, as follows : 



FKACTURES OF THE CEANIUM 



191 




FlG. 169. — Trephine opening for subdural hemorrhage. Opening has been made 
with a Hudson trephine. (Modified after Rawling.) 



,;*■>::,,:, 



■y:4&% 



Fig. 170. — Enlargement of trephine opening with rongeur forceps, and incision of 
dura. (Modified after Rawling.) 



192 



TEEATISE OX FRACTUBES 



\ 




FlG. 171. — After washing out subdural clot, a rubber tube drain is inserted and the 

dura closed by interrupted sutures about the drain. The end of the latter is carried 

through the temporal fascia and skin. (Modified after Rawling.) 





) / 



/■•■ 






Fig. 172. — Shows suture of the temporal muscle by interrupted sutures of catgut, 

and partial closure of the temporal fascia. The fascia is sutured and the skin closed 

with interrupted sutures. (.Modified after Rawling.) 



FBACTUKES OF THE CEANIUM 193 

Class A. — Subdural hemorrhage without serious injury to brain: 
36 cases; 22 recovered after operation; 14 died — 11 without and 3 
after operation. 

Class B. — Subdural hemorrhage with serious brain injury: 36 cases; 
6 recovered after operation; 30 died — 10 without and 20 after operation. 

Summary of Treatment of Cranial Fractures 

Closed fissured fractures .... 1. No evident depression, no brain 

symptoms No operation 

2. No evident depression, with 

brain symptoms Incise scalp and 

open skull 

3. With evident depression, no 

brain symptoms Incise and probably 

open skull 

4. With evident depression, with 

brain symptoms Incise and open skull 

Closed comminuted fractures . . 5. No evident depression, no brain 

symptoms Incise scalp and 

probably open skull 

6. No evident depression, with 

brain symptoms Incise and open skull 

7. With evident depression, no 

brain symptoms Incise and open skull 

8. With evident depression, with 

brain symptoms Incise and open skull 

Open fissured fractures 9. No evident depression, no brain 

symptoms No operation but 

treat wound 

10. No evident depression, with 

brain symptoms Open skull 

11. With evident depression, no 

brain symptoms Open skull 

12. With evident depression, with 

brain symptoms Open skull 

Open comminuted fractures . 13. No evident depression, no brain 

symptoms Probably open skull 

14. No evident depression, with 

brain symptoms Open skull 

15. With evident depression, no 

brain symptoms Open skull 

16. With evident depression, with 

brain symptoms Open skull 

Punctured fractures 17. In all cases Open skull 

Treat all cases as incipient encephalitis, and if primary operation decided upon as 
necessary, do not delay more than a few hours. 

The treatment of gunshot fractures of the cranium, most of which 
are penetrating or perforating, is quite a specialized branch of cerebral 
surgery. Localization of the missile by means of fluoroscopy and study 
of X-ray plates should be an early step. When this is impracticable, 
except after hours of delay, it will probably be found wise to freely open 
the wound of entrance, and that of exit if the injury be a perforating 
one, and trephine the cranium. This will permit removal of fragments 
driven into the membranes or brain and provide for drainage. The bullet 
or shell fragment should not be searched for blindly, but be allowed to 
remain for later attention, unless readily discovered and extracted. 
13 



CHAPTER VIII 

FRACTURES OF THE BONES OF THE FACE 

Anatomy. — Anatomically the bones of the face comprise the two 
nasal bones, the two lachrymal bones, one vomer, the two inferior tur- 
binated bones, the two superior maxilla?, the two palate bones, the two 
malar, one inferior maxilla, and one hyoid bone. On account of the close 
relation with each other individual fractures of facial bones are generally 
limited to the nasal, the superior maxilla, the malar, and the inferior 
maxilla. Fractures involving the other facial bones are either in con- 
junction with the bones of the cranium, or are associated with, fractures 
of the nasal or superior maxilla. 

Fractures of the bones of the face are usually caused by severe direct 
violence and the result is generally fracture of several bones. This is 
particularly seen in fractures of the nasal bones and of the superior maxil- 
lary. In fracture of the nasal bone the nasal spine of the frontal, the 
nasal process of the superior maxillary, the ethmoid and the vomer may 
also be involved. In fracture of the superior maxillary, the malar, the 
nasal, lachrymal, and palate bones may also be fractured. Owing to the 
great vascularity of the parts and the character of the bone, union gener- 
ally takes place rapidly with the formation of a small amount of callus; 
and deformities are frequent unless early reduction of the fragments is 
performed. It is unwise in comminuted and in open fractures of facial 
bones to remove hastily fragments which have apparently slight attach- 
ment to the parent bone. Necrosis of such pieces is unusual. Even when 
the line of break communicates with the nose or mouth, union may take 
place unless the infection occurring is virulent. 

Fractures of the Nasal Bones 

Anatomy. — The nasal bones (Fig. 173) are two flattened triangular- 
shaped bones which unite in the median line to form the bridge of the 
nose. They articulate above with the nasal portion of the frontal. The 
arched bridge made of the two nasals articulates laterally with the nasal 
processes of the two maxillary bones and rests in the middle line upon the 
perpendicular plate of the ethmoid. In addition there are five nasal 
cartilages of the nose, two upper and two lower lateral and the quad- 
rangular. The vomer lies in the middle line of the skull beneath the 
perpendicular plate of the ethmoid bone and the lower edge of the quad- 
rangular septal cartilage of the nose. Any or all of the osseous and 
cartilaginous structures may be involved in fractures. 

Fractures of the nasal bones may involve the nasal processes of the 
frontal and superior maxillary, the cartilaginous septum, the lateral carti- 
194 



FRACTURES OF THE BOXES OF THE FACE 195 

lages of the nose, the perpendicular plate of the ethmoid, the vomer, and 
lachrymal bones. Fractures of the nose are often comminuted and may 
be complicated with a tear of the nasal mucous membrane. 

The cartilages and bones, forming the framework of the nose, are 
united with each other and with their neighbors by sutures at which 
normally there is no motion. If dislocation occur between a bone of 
the nose and an adjoining bone or cartilage, the rupture of the suture 
line is similar to a fracture of bony tissue. 

Fractures of the nasal bones (Figs. 174-179) are due to direct 
violence. The displacement of fragments is primarily due to the force 
and direction of the fracturing force, and secondary displacement may 



Fig. 173a- Fig- I73&- Fig. 173c. 




Upper Lateral 
Cartilages 




Fig. 173a. — Diagram of side of nose showing relations of bones and cartilages. 

Fig. 1736. — Diagram of the bones and cartilages of the nose, anterior view. 

Fig. 173c. — Diagram of the septum of the nose. (From Roberts's Surgery of Face.) 

be due to handling, blowing of the nose, and sneezing. Displacement is 
never produced or made recurrent by attached muscles. 

The most common forms of fracture are: i. A transverse lesion 
near the middle in which the lower fragment is driven backward at an 
angle with the upper fragment. In this fracture the quadrangular carti- 
lage may receive the force of the blow, and be drawn backward with the 
lower portion of the nasal bone which has been broken off. As a result 
the cartilage may be fractured, bent, or dislocated from its attachment 
to the upper border of the vomer; or its lower anterior angle may be 
torn loose from the cartilaginous portion of the septum, or from its 
connection with the maxillary bones at the anterior end of the vomer. 

2. Fractures in which the comminuted fragments are driven directly 
backward so as to lie behind the nasal processes of the maxillary bones. 
Instead of a fracture, or coincident with the fracture, a luxation may 
occur between the nasal bone and the nasal process of the maxilla; or 
the nasal bones, while remaining attached to each other in the medium 
line, may be dislocated and occupy a somewhat similar relation to one 
or both maxillae. 

3. Fractures produced by a blow upon the side of the nose. In these 
cases the nasal bones may be luxated together, the outer edge of the 
nasal bone on the side of the injury being driven under the border of 
the maxillary process, while the outer edge of the other nasal bone is 
displaced on top of. the maxillary process. In severe injuries the nasal 



196 



TEEATISE OX FEACTUEES 







Pig. 174. — (A) Fracture of nasal bones and nasal process of left maxilla. Both nasal bones were fractured 
near lower end and a small piece was detached from the anterior margin of the left maxilla. Great deflection 
of front part of ethmoid and middle of vomer to left. (B) Fracture of nasal bones and nasal process of 
right maxilla. Fracture of both nasal bones transversely at middle. Union with deformity, consisting of 
deflection of nasal bones to the left. (C) Fracture and dislocation of nasal bones. Transverse fracture of 
both nasal bones near the middle. Union without much displacement. 



Fig. 



Fig. 176. 




Figs. 175 and 176. — Photographs showing depressed healed fractures of right frontal, malar, superior 
maxilla, and nasal bones. Injured by a fall of coal while working in the coal mines three years previously. 

Lateral and anterior views. 



FRACTUKES OF THE BOXES OF THE FACE 197 

processes of the superior maxillary bone may be fractured as well as the 
nasal bones themselves. 

The frontal bone and the horizontal plate of the ethmoid bone may 
be involved in severe fractures of the nose in such a way that the frag- 
ments are driven into the cranial cavity. Impaction is usual in these cases. 
The frontal sinus is very likely to be opened, and meningitis may develop 
as a result of infection. The cribriform or horizontal plate of the 
ethmoid is not likely to be fractured when the force injuring the nose 
spends its strength upon the lower third of the nasal bones. It is the 
perpendicular plate of the ethmoid bone that then bears the brunt of 
the injury. 

Fractures from force applied to the upper border of the nasal bridge 
generally involve the ethmoid, while in , 
those cases in which the force is received 
upon the lower part of the nose the quad- 
rangular cartilage of the septum and the 
vomer are most apt to be injured, the 
line of fracture is perhaps more fre- 
quently horizontal in its general direc- g? 
tion than vertical, and a luxation of the 
cartilage from the vomer is more com- 
mon than from the ethmoid. In many \ 
instances, however, the fracture is asso- 
ciated with dislocation of the cartilage 
from the vomer or the ethmoid bones, 1 
and may assume more or less the char- fig. 177.— Photograph showing profile of 

. r 1 ' 1 r , i-i , • case of fracture of nasal bones with depression 

aCter Ot a trmgUlar tractUre-dlSlOCatlOn. of fragments. Fracture produced by direct 
i-r>i r , r ,1 , -i r violence while turning a handspring. 

the fragments of the cartilage or of 

bone and cartilage may override, so that the line of the bridge of the 

nose shows a marked depression in the region of the lateral cartilages. 

The lateral cartilages, which form the lower portion of the bridge of 
the nose, may be dislocated from the lower border of the nasal bones 
and from each other. 

Methods of Examination. — The rapid swelling which accompanies 
these fractures of the nose soon obscures deformity in its framework, 
and causes many fractures and luxations to be overlooked. Anaesthesia 
with nitrous oxide or ether should be employed, if a careful examination 
cannot be made without great pain. Local anaesthesia with novocaine 
and adrenalin may be sufficient. Reflected light from a head mirror is 
desirable in examination, because persistent obstruction to respiration 
from unreduced septal injuries may lead to mouth breathing and its 
attendant sequelae. Saddle-nose, bent nose, twisted nose, and occlusion 
are frequent witnesses of unrecognized and untreated fractures of the 
nasal bones. 




198 



TEEATISE OX FKACTURES 



Symptoms. — Rapid swelling of the soft parts, bleeding from the 
interior of the nose, deformity, external and internal crepitus when frag- 
ments are not impacted, and preternatural mobility of parts of the nose 
are the more important of the early symptoms of fractures. Of the 
later symptoms may be mentioned subconjunctival ecchymosis, subcuta- 
neous hemorrhage in soft tissues of nose and cheeks, and emphysema of 
eyelids and cheeks, indicating involvement of the accessory sinuses in the 
lines of fracture. Epiphora or imperfect drainage of tears from the eye 
to the lower nasal meatus is presumptive evidence that the nasal duct has 
been obstructed by swelling of its lining mucous membrane, or by dis- 
tortion of its bony wall by reason of associated fracture of the maxilla, or 
by complete laceration of the duct in association with fracture. The 



Fig. 178. 



Fig. 179. 




Fig. 178. — Skull; old fracture of nasal bones and left zygoma. The nasal bones were fractured in the 
middle and have united with decided depression of the nose. The nasal septum is deviated strongly to 
the left. The left zygoma was fractured at the summit of the arch but has united. (, Mutter Museum, 

No. 1169.09.) 
Fig. 179. — Skull; fracture of the nasal bones; union. The bones are fractured transversely at the middle 
and have united with a decided deflection to the left. The vomer is extremely displaced to the right. 

(.Mutter Museum, No. 1169.06.) 



external forms of deformity may consist in flattening or depression of 
the bridge of the nose, broadening of the nasal arch as well as flattening, 
and lateral deviation with or without angularity. Dislocation of the 
lateral cartilage from the lower margin of the nasal bone produces a hol- 
low in the dorsum of the nose near the junction of the middle and lower 
thirds. Deviations of the cartilaginous or bony septum accompany many 
fractures of the nasal bones. One or both nostrils may be obstructed by 
an oblique position of a septal fragment. 

Diagnosis. — The diagnosis of fractures of the nasal bones may be 
made by careful examination, particularly through the anterior nares with 
the aid of a speculum and good light, eliciting some of the above symp- 



FEACTUBES OF THE BOXES OF THE FACE 



199 



toms. External deformity, generally present, may be obscured by the 
rapid swelling. Deviation of the nasal septum ma}' or may not be present. 
The principal form of deviation of the septum seen in conjunction with 
fracture of the nasal bones is a lateral displacement of the tip, and the 
most common form of fracture is a horizontal one producing a gutter-like 
deformity in a horizontal plane. A triangular fracture-dislocation may 
cause a V-shaped piece of the septum to be driven backward with the 
point toward the pharynx. 

Complications. — The complications of nasal fractures are prolonged 
suppuration in compound comminuted fractures, followed by abscess of 
the soft parts and periostitis, perichondritis of bone or cartilage; involve- 




FlG. 180. — Mosher's method of reducing, with thumb and elevator, fracture dis- 
location of nasal bones, when right nasal bone overrides maxillary process and 
left is depressed and caught under its fellow and under the left maxilla. 



merit of the frontal sinus in the line of fracture, producing emphysema 
of the subcutaneous tissues; extension of the line of fracture to the 
anterior fossa of the skull with accompanying intracranial injury or 
meningitis; involvement of the cartilaginous or bony septum resulting in 
marked deviation; involvement of the lachrymal duct due to the line of 
fracture involving the nasal process of the superior maxilla with re- 
sulting epiphora. 

Prognosis. — Union generally takes place in two to two and a half 
weeks. 

Treatment. — It is essential that all recent fractures of the nasal bones 



200 



TEEATISE OX FRACTURES 



be promptly and skilfully treated so that deformity from unreduced or 
carelessly replaced structures may be averted. Injuries which are insig- 
nificant, so far as danger to life is concerned, may leave distortions of 
the outline of the nose or obstructions to breathing of great importance. 
Cosmetic reasons, therefore, and the necessity of having unobstructed 
nasal ventilation and breathing, especially in children, should stimulate 
medical attendants to give attention to nasal injuries. The proper de- 
velopment of the accessory sinuses and the associated contour of the 
jaws and other parts of the face depend upon free nasal ventilation in 
early childhood. 

Recent Fractures. — The character of the injury and the form of dis- 
placement are to be determined by palpation of the exterior with the 
fingers, assisted by a rigid slender instrument within the nose for counter- 
pressure. Elevation and restoration of the depressed or displaced frag- 



FlG. I 



Fig. 182. 




Quadrangular 
Cartilage 



Fig. 181. — Diagram of septal lesions due to blow from in front. Observe the V-shaped fracture- 
dislocation of quadrangular cartilage and the overlapping of the V on the vomer. _ There may be a 

dislocation from both ethmoid and vomer, or partly a fracture and partly a dislocation. 

FlG. 182. — Roberts's use of pins to hold fragments of fractured septal cartilage in corrected position. 

One pin is thrust through the dorsum, the other is inserted into the nostril. 



merits of the osseous arch of the nose may best be accomplished by intro- 
ducing a narrow steel instrument into the nostril. This steel rod must be 
narrow enough to go to the top of the space between the nasal bone, the 
ethmoid plate, and the nasal process of the maxilla. By thrusting upward 
under the nasal bone and by proper manipulation externally, the surgeon 
can generally mould the displaced fragments into place (Fig. 180). Con- 
siderable force may at times be necessary to separate impacted fragments. 
Displacement of the nasal septum may be restored after careful exam- 
ination by means of a forceps with fiat and wide blades. The septum 
is grasped by the introduction of a blade into each nostril, and the displaced 
portion pulled forward and its posterior end tilted upward by depres- 
sion of the handles of the forceps. These manipulations, combined with 
lateral movements, will restore usually the line of the nasal bridge from 



FRACTURES OF THE BONES OF THE FACE 201 

forehead to the tip of the nose, and replace the obstructing fragment of 
cartilage or bone into the middle of the cavity of the nose. If some 
time has elapsed since the injury, so that partial union of the displaced 
fragments has occurred, strong lateral movements with the forceps 
will generally be necessary to break up the fibro-osseous union and per- 
mit reposition. 

The corrected position of the nasal bones, lateral cartilages, and septal 
structures is to be maintained by internal splints, by nasal pins, or by 
external pads attached to forehead bands. The last are seldom necessary 
and generally accomplish very little. There is usually little or no tend- 
ency to recurrence of displacement of fragment after proper reposition, 
unless the patient handles his nose or blows it violently. When such a 
tendency exists because of great comminution, the parts may be retained 
in place by filling the internasal space with gauze packing, or preferably 
by tubular nasal splints. Occasionally pins may be used to* hold fragments 
in position (Figs. 181 and 182). Their use, however, is not advocated, 
except in a few well-selected cases. Their disadvantages are the presence 
of an open wound and the resultant scar at the site of the pin-holes. 
These objections are, however, not serious, if the pins and punctures are 
made aseptic. 

Old Unreduced Fractures. — These cases call for osteotomy and re- 
fracture with readjustment. Division of cartilage and bone may be 
performed through small external incisions or through puncture wounds 
of the mucous membrane. After osteotomy and re-fracture have been 
performed and readjustment completed, the external wound may be 
closed with collodion dressings. Internasal splints should be used to 
maintain reduction. In saddle-back deformities of the nose due to 
fracture, the normal external contour may be gained by the use of subcu- 
taneous injections of paraffin. This material is injected with a syringe 
having a piston driven by a screw attachment and needle of large calibre. 
It may be injected when in a fluid state from heat and moulded into a 
proper contour. The cooling causes solidification and the new nasal out- 
line is permanent. 

Lateral deformities involving the cartilaginous and bony ridge are 
as a rule accompanied by deviations of the cartilaginous and bony septum 
with occlusion of one or both nostrils. In these cases the prominence of 
the septum should be removed by a submucous resection to a point a quar- 
ter of an inch from the top of the cartilaginous bridge. If the lateral 
cartilages are displaced, their position is corrected by intranasal opera- 
tions. The nasal bones are then chiselled loose and returned to their 
normal position. In all these cases proper internal retentive apparatus 
should be used for at least four to seven days and the nasal cavities should 
be kept as clean as possible by dry antiseptic packing or by douching. 



CHAPTER IX 

FRACTURES OF THE MALAR AND MAXILLARY BONES 

Anatomy. — The malar or zygomatic bone has two surfaces — the 
facial and the posterior, and articulates with the frontal, sphenoid, maxil- 
lar, and the temporal bones; and has four processes, the frontal, the 
orbital, the maxillary, and the temporal. 

Surface Markings. — The malar bone forms the prominence of the 
cheek. Its external surface may be readily palpated, and where it ex- 
tends backward can be felt the prominent zygomatic arch. Above this is 
situated the temporal fossa in which can be plainly felt the movement of 
the temporal muscle during mastication, and pulsation of the anterior 
branch of the temporal artery. 

Fractures of the malar bone are the result of direct violence, either 
from without, as that of a blow or a fall upon a blunt object, or from 
within, as in a fall upon a stick held within the mouth. Isolated fractures 
of the malar bone are rare. They are seen usually in conjunction with 
fractures of the superior maxilla or of the frontal bone. The severe 
forms are accompanied by cerebral concussion and occasionally by an 
extension of the line of fracture to the base of the skull. Fractures of the 
malar bone may involve the orbit or the maxillary antrum. 

Methods of Examination. — This is best accomplished by having the 
patient seated upon a chair. The surgeon standing back of him palpates 
the malar bones with his two hands at the same time (Fig. 183). Any 
irregularities or depressions will be readily detected. The entire external 
surface, the inferior surface, the zygomatic process, the malar portion of 
the orbital margin, the frontal process, may be readily examined. 

Varieties of Fracture. — Fractures of the malar bone may involve the 
body or its processes. Those of the body are of various degrees, depend- 
ing upon the direction and degree of the fracturing force (Figs. 184 and 
185). They form the greatest number of fractures of this bone. The 
external surface is crushed inward toward the maxillary sinus, and the 
fracture generally involves the superior maxilla. Fractures of the zygo- 
matic arch (Fig. 186) alone are rare, and are generally due to external 
direct violence, although they may result from force transmitted through 
a stick held in the mouth. The fragments are usually displaced in the 
direction of the fracturing force. The fragments may be driven inward 
and so produce pressure upon the coronoid process of the inferior maxilla 
or the tendons of the temporal muscle, making movements of the lower 
jaw difficult or impossible. Separation of the entire malar bone from the 
remaining portion of the facial skeleton occurs, but true suture disjunction 
202 



FEACTUBES OF THE MALAR AND MAXILLARY BONES 203 

is very rare. In these cases the lines of fracture are near the suture lines 
and generally involve the processes of the frontal, temporal, and superior 
maxillary bones, combined with fracture of the zygoma. Fracture with 




FlG. 183. — Method of palpation of malar bones. Any irregularities or depressions 
will be readily detected. 



Fig. 184 



Fig. 




Fig. 3:84.— Lower half of skull. Fracture of the left malar; union. The bone was fractured close to its 
junction with the superior maxillary. Union has occurred, incomplete inferiorly and marked by a spicule 

at the margin of the orbit, pointing toward the nose. (Mutter Museum, No. 1169.08.) 
Fig. 185. — Skull; old fracture of the nasal and left malar bones. The fracture occurred close to the 
upper border of the nasal bones and from the orbital margin of the malar toward the inferior angle, 
The deformity of the nasal fracture consists of a decided depression on the left side in which the internal 
angular process of the left frontal has shared. There is a fissure in the malar and slight exostosis on the 
orbital margin. From a sabre cut. (Mutter Museum, No. 1 169. 10.) 



dislocation and displacement of the entire bone into the maxillary sinus 
is possible. For this rare injury the fracturing force must be great; and 
the entire bone, together with the zygoma, may be forced into the maxil- 
lary sinus. Fractures with dislocation of the bone into the orbit or into 



204: 



TEEATISE OX FRACTURES 



the sphenomaxillary fossa have occurred. The last three varieties of 
fracture are rare, are the result of great violence, are generally accom- 
panied by fractures of other of the facial bones, and the line of fracture 
frequently involves the base of the skull. 

Symptoms. — These injuries are recognized by the deformity, the 
irregularity of outline, and crepitus. There is flattening of the cheek 
to the outside and below the orbit. In addition there is generally sub- 
conjunctival ecchymosis and occasionally protrusion of the eyeball. Mo- 
bility as well as crepitus may occasionally be discovered. Of the rarer 
symptoms there may be areas of anaesthesia corresponding to the dis- 
tribution of the superior maxillary nerve, which may be injured when 

the line of fracture extends into the 
floor of the orbit. The bleeding from 
the nose, due to laceration of the 
mucous membrane of the antrum, 
difficulty in movements of the lower 
jaw, due to pressure of fragments of 
the zygomatic arch upon the masseter 
muscle and coronoid process of the 
inferior maxilla, or fracture of the 
latter in conjunction with fracture of 
the zygomatic arch are occasional evi- 
dences of the fracture. 

Diagnosis. — The diagnosis of frac- 
ture of the malar bone may best be 
determined by deformity. Mobility 
and crepitus are rare. Deformity is 
generally masked by swelling. If one, 
however, carefully palpate the two 
sides of the face at the same time, 
the change in facial contour may be 
discovered; and if in addition to 
slight flattening of the body of the 
malar bone there is subconjunctival ecchymosis, bleeding from the nose, or 
localized swelling, one may pretty safely conclude that there is a fracture. 
Radiography may confirm the diagnosis. Fracture of the zygoma may 
be readily recognized by the presence of swelling of the soft parts, the 
evident depression of the arch, and the limitation of motion of the 
lower jaw. 

Complications. — Of these the most important are injury to the superior 
maxillary nerve, the eyeball or optic nerve, seen in extensive dislocations 
of the entire malar bone into the orbit, and fracture of the anterior cere- 
bral fossa in extensive communicating fractures. 

Prognosis. — This is generally good unless there is laceration of the 
superior maxillary or optic nerve or an extension of the fracture lines 




Fig. 186.— Skull; fracture of left malar. The 
left malar was fractured obliquely, downward 
and forward, near the zygoma. Union has 
occurred with slight depressions of the zygo- 
matic arch. (Mutter Museum, No. 1169.20.) 



FBACTUKES OF THE MALAR AXD MAXILLAEY BOXES 205 

into the base of the skull. Malar fractures heal in about two weeks with 
the formation of little callus, hence reposition of fragments should be 
made as soon as possible. Otherwise varying degrees of flattening of 
the face over the malar bone or zygomatic arch will remain as perma- 
nent disfigurements. 

Reduction of displacement of fragments is to be obtained by pressure 
with the surgeon's fingers upon the cheek or within the mouth, unless a 
cut in the soft parts is made to permit introduction of a steel elevator. 

Treatment. — In many cases it is difficult to obtain complete replace- 
ment of fragments. In fracture of the zygoma it is possible to elevate 

Fig. 187. 




Fig. 187. — Lothrop's method of reduction of depressed and comminuted fractures of the malar and 

superior maxilla. 
Fig. 188. — Matas's method of reduction of a depressed fracture of the zygomatic arch. (See Fig. 187.) 



depressed fragments by means of an incision through the skin and direct 
elevation. In fractures of the body of the bone this method is not so 
feasible, as it may be impossible to maintain reduction of the fragments. 
Depression of the body of the bone down into the antrum of Highmore 
may be corrected by the method devised by Hamilton and also by Howard 
A. Lothrop (Fig. 187). This consists in making an incision through the 
mucous membrane of the canine fossa of the superior maxilla, breaking- 
through into the antrum with a sharp chisel, and elevating the depressed 
fragments by means of a curved steel instrument. A 2 1 F. urethral sound 
is ideal. After thorough elevation, packing the antrum with a strip of 
gauze is a wise procedure. This is left in place for five days; then the 



206 TREATISE OX FRACTURES 

antrum is irrigated with warm boric acid solution for several days. After 
removing the gauze it will be found that sufficient union has taken place 
to hold the fragments in their corrected position. 

Sometimes the body of the fractured bone may be drawn forward 
into position by making small incisions above and below and grasping its 
edges by a pair of forceps shaped like the tongs used for carrying blocks 
of ice. In old fractures of the malar bone with deformity, it is generally 
possible to correct the depression by subcutaneous injection of paraffin, 
or the transplantation of a ball of fatty tissue, which may be cut from 
the abdominal wall. 

Depressed fractures of the zygomatic arch may be reduced by the 
method of Matas (Fig. 188), which consists in introducing a hook 
through a small punctured wound below the arch and pulling the dis- 
placed fragment outward, or by an elevator introduced through a quarter- 
inch incision above the arch. This replacement of a depressed fragment 
may be accomplished also by carrying a strong thread or wire under the 
arch by means of a semicircular needle. Traction on the two ends of 
the wire will raise the driven-in portion of the arch. 

Fractures of the Maxilla 

Anatomy. — The upper jaw is made by the junction, in the middle 
line of the face, of the right and left maxillary bones. The alveolar 
processes of the component pieces form the superior dental arch, in which 
are developed the upper teeth. In normal closure of the mouth, the 
biting edge of the incisor teeth of the maxillae are a little farther forward 
than those of the mandible. The surgeon should be familiar with the rela- 
tive positions of the teeth in the child and the adult. 

The two upper jawbones occupy the middle of the face, and help 
to form the floor of the orbits, the roof of the mouth, and a considerable 
portion of the nasal fossae. Each maxilla consists of a body and four 
processes : the frontal or nasal process, the zygomatic process, the palatine 
process, and the alveolar process. The thin-walled body contains a large 
cavity, the maxillary sinus or antrum of Highmore, and has four surfaces : 
the anterior, the orbital, the infratemporal, and the nasal. 

The anterior surface can be readily palpated as well as the palatine 
process and nasal surface. 

Pathology. — Fractures of the superior maxilla are frequently accom- 
panied by fracture of the malar, nasal, lachrymal, or palate bones. The 
injury is apt to be due to violence acting directly upon the bone, such 
as a blow, a fall upon the face, the kick of a horse, the extraction of 
teeth, and gunshot wounds. This method of production is the cause 
of the injury being frequently an open fracture. Indirect violence, 
through transmitted force as seen in fractures of the malar or nasal bones, 
may occasionally cause the superior maxilla to be broken. 

The outline of the body and the various processes of the superior 



FRACTURES OF THE MALAR AND MAXILLARY BONES 207 

maxilla may be readily palpated. Its fracture may be readily determined, 
especially if an anaesthetic is used. The effect of displacement of frag- 
ments upon the contour of the face and the normal shape of the orbital, 
nasal, and oral cavities makes injuries of the maxilla important. Assur- 
ance of the integrity of the maxilla or of its freedom from fracture 
distortion is incumbent upon the surgeon, after severe blows upon the 
face. This precept is equally imperative in regard to fractures of the 
nasal, malar, and mandibular bones of the face. The primary swelling 
is liable to conceal the deformity due to displaced fragments, and the rapid- 
ity of consolidation makes late reduction difficult. Radiographic exam- 
ination is at times essential. 

Partial fracture of the alveolar process, the palatine vault, the nasal 
process, and the maxillary sinus walls may occur. 

Gross fractures are intermaxillary separation or disjunction, hori- 
zontal fractures of three types, separation of the entire alveolar process, 
double horizontal fracture of A. Guerin, and craniofacial disjunction. 

Perforating fractures, generally of the hard palate and floor of the 
orbit, are seen as the result of gunshot and penetrating wounds, often 
through the mouth. 

Fractures of the body, frequently comminuted, usually involve the 
antrum of Highmore. They are also seen in conjunction with fractures 
of the malar or nasal bones. 

Fractures of the alveolar process are due to direct violence, as a 
blow or a fall upon the face, or to the unskilful extraction of teeth. 

Definite fracture lines according to the direction of the force have 
been ascertained in fractures of the superior maxilla by the investigations 
of A. Guerin : A transverse fracture runs backward into the pterygoid 
process almost i cm. below the malar bone on both sides and is the result 
of a severe blow from before backward below the nostrils in the median 
line or somewhat to the side. There may be entire displacement of the 
vault of the mouth with the alveolar processes posteriorly. The pterygoid 
processes are fractured at the level of the lower border of the pterygoid 
maxillary fissure. Fissuring of the palate bones from before backward 
may also take place. If the fracturing force is lateral and corresponds 
to the level of the palate, the above form of fracture results, and if the 
direction of the force is sagittal there is a fracture of the pterygoid 
processes in addition. When the fracturing force is lateral and oblique 
from above downward, the alveolar process is detached and also a portion 
of the body of the bone, depending upon the level of the fracturing force. 
When the fracturing force is from below upward there may be fissures 
surrounding the malar bone; and when the force is severe and bilateral 
there may be detachment of the entire median portion of the bony face, 
with extension of the fracture lines from the nasal apertures toward the 
orbits. Fissure fractures of the palate may also be present. A severe 
blow received from a broad surface acting upon the superior maxillary 



208 TEEATISE OX FRACTURES 

and malar bones may cause complete detachment of the facial bones 
from the skull proper. This form of injury has been observed by Doctor 
Kelly in the case of an elevator accident. 

Symptoms. — The symptoms of fracture of the superior maxilla are 
in great degree dependent upon severity of injury. The principal symp- 
toms are swelling, ecchymoses, asymmetry, crepitus and mobility of 
fragments. Many of these fractures may be compound into the nasal 
or oral cavities and communicate with the antrum of Highmore. Lacer- 
ations of the mucous membrane of the latter may lead to emphysema 
of subcutaneous tissues. A careful inspection of the nasal and oral 
cavities should be made. Close observation of the relation of the upper 
teeth to each other and to those of the lower dental arch may reveal unsus- 
pected fracture lines. At times a general anaesthetic will be necessary. 

In severe injuries the lines of fracture may extend into the base of 
the skull and there may be coincident injury to the intracranial contents. 

Compression or laceration of the lachrymal duct, injury to the superior 
maxillary nerve, injury to the orbital contents, meningitis, severe 
hemorrhage, periostitis, necrosis of bone are occasional complications 
of maxillary fracture. 

Diagnosis. — Examination of the surface of the face, the interior 
of the nose, and mouth will disclose the nature of the fracture. If there 
is no displacement of fragments, examination may detect the source of 
the hemorrhage and the possible tear in the mucous membrane. Fractures 
of the body will show some irregularity of surface contour. Fractures of 
the alveolar process will be determined by crepitus, mobility, and irregu- 
larity in the outline of the teeth. Emphysema of the subcutaneous tissues 
points to injury involving the antrum. In severe injuries, the diagnosis is 
evident from the asymmetry, crepitus and mobility of the fragments, 
although it may be impossible to determine the full extent of the line of 
fracture. The liberal arterial supply causes rapid healing of the broken 
bone, and even in comminuted and infected fractures healing may be 
rapid. Fragments should not be hastily removed for fear of necrosis. 
Delay will often prove that vitality of the bone has not been destroyed. 
Secondary thickening of periosteum about the necrosing piece may be 
valuable to retain the normal contour of the maxilla and aid in main- 
taining the dental arch. Existence of involvement of the base of the 
skull is unlikely unless symptoms of intracranial injury develop. 

Prognosis. — In uncomplicated cases union of the fragments gener- 
ally takes place in three or four weeks without the formation of much 
callus and with little deformity. Severe neuralgia may persist for a long 
time from involvement of branches of the superior maxillary nerve in the 
callus, and epiphora may persist due to obliteration of the lachrymal 
duct. Necrosis of bone is rare because of the abundant blood supply, and 
even portions that are detached ma) unite. On this account all portions 
of bone necessary for the contour of the face and alveolar process should 



FEACTFEES OF THE MALAE AND MAXILLAEY BONES 209 

be preserved if possible. Displacement of fragments, if slight, is not 
noticeable after healing takes place. When the nasal or other adjacent 
bones are also fractured the displacement is apt to be severe, in which 
event deformity may be permanent. 

Treatment. — In treatment of these fractures loose teeth should be 
left in place, as they frequently become permanently fixed again. Many 
disjunctions are readily reduced but difficult to keep in place; union gener- 
ally results with a certain degree of deformity. This may be prevented 
in some cases by cutting down on the fracture and suturing fragments 
with chromicized catgut, or using nails or screws for direct fixation. Re- 
construction of the normal contour of the hollow body of the maxilla 
may sometimes be best obtained by incising the mucous membrane under 
the upper lip and thus reaching the anterior surface of the bone. The 
maxillary sinus itself may be entered and direct pressure be exerted on 
the walls from the mouth in this submucous manner. 

Loose fragments of bone should not be removed primarily because 
repair may take place without necrosis. In all open fractures into the 
mouth, nose, or maxillary sinus thorough cleanliness should be ob- 
served. Frequent douching of the nose is then desirable, and some 
form of mild antiseptic solution, as a gargle, should be used. Tartar 
should be removed from the teeth, which should be kept as clean as pos- 
sible. Retention of the fragments may be secured after reduction by the 
use of interdental splints of vulcanite or metal which utilize the mandible 
to steady the fractured maxilla. An interdental splint applied to the 
upper dental arch and having lateral projections from the mouth 
may be used to hold up the maxillary fragments in transverse frac- 
ture of the upper jawbones. The splint is fixed firmly by straps across 
the crown of the head. When possible these patients should be 
placed in the hands of a skilled oral or dental surgeon, who is able to apply 
the proper form of interdental splint. During the three to four weeks 
in which closure of the mouth is needed, liquid food is introduced through 
the crevices between the teeth, or by a tube passed between the alveolar 
arch and the cheek back to the last molar tooth. An intermaxillary splint 
with an opening for the administration of liquid food may be used. 
Severe industrial injuries of this region of the face require surgical 
treatment and plastic repair similar to that demanded by war fractures. 

When the fracture involves anterior and lateral portions of the 
antrum of Highmore, an accompanying fracture of malar bone may be 
present with depression of the superior maxillary and malar bones inward. 
Reduction may be accomplished by the method of Lothrop (Fig. 187) or 
some similar manoeuvre. Annoyance from continuous flow of saliva 
occurring in severe fractures may be alleviated by placing lampwicks into 
the mouth at the corners and applying absorbent pads at the sides of 
the chin. If the sinus has been opened, irrigations with a mild antiseptic 
solution should be employed. Otherwise a mouth-wash is sufficient. 
14 



CHAPTER X 

FRACTURES OF THE MANDIBLE 

Anatomy. — The inferior maxilla, or mandible (Fig. 189), is the only 
bone of the skull connected with the others by a joint. It is composed 
of a body and two rami. The body is horseshoe in shape, from the pos- 
terior extremities of which ascend the two rami. The bone may be con- 
sidered as a union of two symmetrical halves, which form the framework 
of the lower part of the face. The body has a base, or inferior portion, 
and an upper or alveolar portion containing the lower teeth. These corre- 
spond in name and number with those of the upper jaw, formed by the 
two maxillary bones united in the middle line of the face. In the adult 
there are usually sixteen teeth erupted in each jaw. In a complete set 
of deciduous teeth of the child there are usually ten teeth in each jaw. 
Occasionally supernumerary teeth are developed and erupted. Sometimes 
one or two teeth are not erupted, but remain within the bone and are 
only disclosed by X-ray examination. A space left between the teeth by 
the extraction of a tooth in early life may be closed by the adjacent 
teeth gradually approaching each other. This should be remembered 
when examining the jaws of patients. On the anterior external surface of 
the body is the mental protuberance, and at each side of this near the 
base a mental tubercle. Above and external to the mental tubercles are 
the mental foramina. 

The lateral portion of the external surface of each half shows an 
oblique elevated line extending downward and forward from the coronoid 
process of the ramus. The internal surface of the body presents the 
digastric fossa, the mental spine, the mylohyoid line, the mylohyoid groove 
and the mandibular foramina. Extending upward from the posterior 
extremities of the body are the rami, at the beginning of which on each 
side is the angle of the inferior maxilla. At the summit of the ramus is 
the condyloid process, the notch of the mandible, and the coronoid process. 

Surface Markings. — The external surface of the mandible can be 
readily palpated externally; and internally its surface markings may be 
examined by a finger in the mouth. The prominent anterior part called 
the symphysis mentis, the ridges or alveolar jugse, the edge of the attached 
masseter muscles, the angle and the coronoid process may be felt through 
the skin; and the examiner can fairly well outline the temporo-maxillary 
articulation under the posterior end of the zygomatic arch. 

Statistics. — Fractures of the inferior maxilla are more frequent than 
of the superior maxilla. They are rare in childhood and old age, and 
most frequently occur between the third and fourth decennium. 

In 1722 fractures, Lente found 66 (3.19 per cent.) in the inferior 
210 



FKACTURES OF THE MAXDIBLE 



211 



maxilla, the fracture occurring' ten times more frequently in men than 
in women. In children mandibular fractures were seldom observed. 
The combined statistics collected by von Bleichsteiner, comprising 156 
cases of fracture of the lower jaw, showed that 56 occurred in the third 
and only 7 in the first ten years of life. Of Gurlt's 143 reported cases 
80 were single, 49 double; and in 14 there were three or more lines of 
fracture. Of the 80 single fractures, 5 involved the alveolar processes, 
in 25 the line of fracture involved the median line, the region of the 
incisor teeth in 22, the region of the molar teeth in 15, posterior to the 
teeth in 8, and the condylar process in 5 instances. In 35 double frac- 
tures in which the line of fracture is described, both sides of the bone 
were involved in 20 instances, generally at corresponding' points; in 
8 cases one side alone was involved, and in the remaining 7 cases the 
median line was involved in one of the fracture lines. 

Etiology.— Fractures of the mandible are usually the result of a blow 



Coronoid process 
Condyloid process 



Ramus 




Mental foramen 



FlG. 189. — Mandible, outer aspect. (Piersol's Anatomy.) 



with the fist, a kick, a fall upon the chin, gunshot injuries, or the faulty 
extraction of teeth. The last form of violence rarely results in a direct 
transverse fracture, but generally in a tearing off of a portion of the 
alveolar process. Most fractures are the result of direct violence. A few 
rare forms of fracture may be the result of indirect violence, as by cough- 
ing, a tearing off of the coronoid process by violent contracture of the 
temporal muscle, or a compression of the jaw from side to side, accom- 
panying a lateral compression fracture of the skull. The site of fracture 
in the last instance occurs near the point of greatest flexion — the sym- 
physis. Fracture of the neck of the condyloid process from a blow on 
the chin is also an example of indirect violence. Bilateral fracture of the 
inferior maxilla is uncommon, although multiple fractures are fairly 
frequent. Hamilton states that they form about one-third of all cases. 
Comminuted fractures are rare. Open, the so-called compound, frac- 
tures are very frequent, because the adherent gum overlying the seat of 
fracture is generally torn. Fractures are rarer through the symphysis. 
Varieties. — Fractures of the horizontal portion are generally open, 
and of the ramus usually closed. The site of fracture depends upon the 



212 



TREATISE OX FRACTURES 



position of the trauma, the manner in which the blow was received, and 
the presence of any weak point in the bone. The following are the 
usual sites of fracture : 

Fracture Through the Symphysis (Figs. 190 and 191). — This is 
very rare. If comminuted, a portion of the bone may be drawn backward 
by the geniohyoid and geniohyoglossus, and at times the digastric muscles, 




Fig. 190. — Fracture of mandible through symphysis. 

and cause symptoms of suffocation. The line of fracture, if single, is 
generally vertical. 

Fracture at or near the mental foramen (Figs. 194 and 195), in the 
region of the canine tooth, are more frequent than those of the median 
line. The line of fracture is generally oblique. This is a weak part of 
the bone, which is strong behind this point on account of the beginning 
of the mylohyoid ridge and the protection afforded by the masseter muscle. 
When the line of fracture runs forward and downward and from within 
out, very little if any displacement occurs. When its direction is down- 



FBACTURES of the mandible 



213 



ward and backward, the anterior portion is depressed by the genio- 
hyoglossus, geniohyoid, mylohyoid, digastric, and platysma muscles, 
and the posterior portion is elevated by the temporal, masseter, buccinator, 
and internal pterygoid muscles. If the fracture is double, the displace- 
ment of the anterior fragment is marked. When the line of fracture runs 
backward from above downward and backward from within out, the 
posterior fragment is drawn in- 
ward by the internal pterygoid 
and mylohyoid muscles, and the 
anterior fragment is drawn up- 
ward by the action of the in- 
ternal pterygoid muscle of the 
opposite side. 

Fracture through the molar 
region (Figs. 196 and 197) is 
not uncommon. Here there is 
very slight displacement of frag- 
ments, due to the firm attach- 
ment of the masseter and in- 
ternal pterygoid muscles. Injury 
to the vessels and nerves running 
in the inferior dental canal are 
disagreeable symptoms which may complicate fractures in this region. 

Fractures through the Angle (Figs. 198 and 199). — A small number 
of fractures occur nere. There is generally slight displacement upward 
and forward of the ramus due to the pull of the masseter and internal 

EXT. PTERYGOID 
^-TEMPORAL MU^r/ F TEMPORAL / 

CONDYLE 




Fig. 191. — Mandible; old fracture of the body; union. 
The line of fracture is midway between the symphysis 
and the right inferior dental foramen. Union occurred 
without deformity, but with a deficiency at the alveolar 
border which exposes the root of the right incisors. 
(Mutter Museum, No. 1 169. 14.) 




PLATYSMA MYOICT MUSCLE 



Fig. 192. — Muscular attachments to the outer sur- 
face of mandible. (Piersol.) 



Fig. 193- 



INTERN PTERYGOID 
MUSCLE 



■Muscular attachments to the inner sur- 
face of jaw. (Piersol.) 



pterygoid muscles with a backward and downward displacement of 
the body. 

Fractures through the ramus (Fig. 200) are extremely rare, because 
of the protection afforded by the attached muscles. The line of fracture 
is generally oblique from in front and above downward and backward. 
Dislocation of fragments is rare unless the fracture is bilateral or com- 



214: 



TEEATISE OX FRACTURES 



plicated by a luxation of the condyloid process of the opposite side. Gen- 
erally the fragments are held in apposition by the masseter and ptery- 
goid muscles. 

Fracture through the condyloid process (Figs. 201 and 202) is 
generally at the neck, is infrequent, and is difficult to treat. Roe reports 
6 out of 41 cases of fracture of the mandible. The displacement in this 
form is characteristic. The chin and jaw are pulled toward the injured 
side, especially by the internal pterygoid muscle of the opposite side. This 




Fig. 194. — Fracture of mandible, near mental foramen. 

lesion is differentiated from forward dislocation by the fact that in the 
latter the chin will point toward the normal side. In bilateral fracture 
of the condyloid processes the entire lower jaw will be pushed upward and 
backward and the lower teeth will be displaced behind the upper teeth. 
Fracture in the glenoid cavity of the temporal bone may exist as a compli- 
cation of this mandibular fracture; as a result of displacement the audi- 
tory meatus may be narrowed. The fissure may invade the cranial wall. 
Fracture through the coronoid process is extremely rare. Moderate 
displacement only of the upper fragment occurs on account of the grasp- 
ing insertion of the temporal muscle. These fractures are generally 



FEACTCEES OF THE MANDIBLE 



15 



the result of direct violence 
and often are accompanied 
by fractures of the malar 
and superior maxilla or base 
of the skull. 

Fractures of the alveolar 
process (Fig. 203) are com- 
paratively frequent. They 
are generally produced dur- 
ing extraction of teeth, or by 
a blow upon the teeth. 

Method of Examina- 
tion. — Examination is ac- 
complished by the inser- 
tion of the index-finger into the mouth while the other fingers, upon the 
chin, seize the lower fragment, and the other hand steadies the upper 
fragment (Fig. 204). By manipulation, displacement of fragments may 




Fig. 195. — Inferior maxilla; ununited fracture. The fracture 

occurred through the left mental foramen; failing to unite, the 

bone is thickened at the seat of fracture and the opposing edges 

are rough. (Mutter Museum, No. 1 169. 13.) 




Fig. 196. — Fracture of mandible, through body. 



216 



TEEAT1SE OX FRACTURES 



be recognized and crepitus may be elicited. It is, however, unnecessary 
to do this in all cases. Simple inspection of the gums in fractures of the 
body will generally show laceration or submucous hemorrhage and mal- 
alignment or looseness of the teeth. 




FlG. 197. — Fracture of mandible, malar region, showing type of displacement of fragments. 




Fig. 198. — Fracture of mandible, through angle. 



fbactur.es of THE MANDIBLE 217 

Symptoms. — The symptoms of a fracture of the mandible are well 
marked in fracture of the body and generally obscure in fractures of the 
ascending ramus. The displacement, crepitus, and unnatural mobility in 
fracture are easily detected, but one should bear in mind the possibility 
of malpositions of the teeth from irregular development and irruption. 
Pain is a most constant symptom in fracture of the jaw. It is increased 
by talking and deglutition, and profuse salivation is generally present. 




<? .f*\PORAL/5 





j 



\ 

; 



Fig. 199. — Fracture of mandibls through malar region, showing type of dis- 
placement of fragments. The ramus is pulled upward, forward, and inward by 
the masseter, temporal, and internal pterygoid while the body is displaced 

backward. 

This increase of saliva and mucus is largely relative, the excess being due 
to the want of proper control of the fluids within the mouth. These fluids 
may be mixed with blood, due to the fact that many of these fractures 
are open. Examination will often disclose a tear of the mucous membrane 
or a submucous ecchymosis, and irregularity of the teeth from improper 
occlusion of the upper and lower rows. In fractures without displace- 
ment, crepitus, or malalignment of teeth, the only symptoms present may 
be swelling, local tenderness and pain, and inability to freely move the 
lower jaw. In fractures of the neck of the condyle there is generally a 
slight depression in front of the external auditory meatus, and on move- 



218 



TREATISE OX EBACTUBES 



ment of the jaw the condyle does not follow its normal range of motion. 
Other late symptoms of fracture are fetor from decomposing food, pus 
and other secretions, abscess about necrosed fragments of bone, fistulous 
tracts and ulcerations of the mucous membrane; and in occasional in- 
stances marked general debility 
clue to the swallowing of foul 
secretions and deprivation of 
nutritious food. 

Complications. — The compli- 
cations of fracture of the in- 
ferior maxilla may be divided 
into those due to traumatism and 
those due to infection. The com- 
plications due to traumatism are 
the immediate and the delayed. 
The immediate are severe lacer- 
ation of face and lips, hemor- 
rhage from laceration of the 
of an artery. Coyler reports 




Fig. 200. — Inferior maxilla; oblique fracture of the 
ramus; ununited. The left ramus was fractured ob- 
liquely in a line running from the sigmoid notch near 
the coronoid process downward toward the angle of 
the bone. (Mutter Museum, Xo. 1 169.21.) 



soft parts and occasional rupture 
a case in which a traumatic aneurism developed, necessitating ligation 
of the common carotid. Additional immediate complications are 
dislocation associated with fracture, dislocation and fracture of the teeth, 
laceration or compression of the inferior dental nerve, fracture of the 




Fig. 201.- 



-Fracture of mandible through neck of condyle. Boy was struck on side of jaw 
by falling rock. Arrow points to displaced condyle. 



FRACTURES OF THE MANDIBLE 219 

base of the skull, and cerebral concussion. The delayed complications 
are involvement of the inferior dental nerve in callus, delayed or non- 
union of the fragments, and union of fragments in such a position that 
correct articulation of the upper and lower teeth is not possible. 




Fig. 202a. — Side view showing the condyloid process "bent" in and forward to 
almost a right angle with the ramus, the head resting in the pterygomaxillary 
fossa. (Courtesy Dr. M. H. Cryer.) 




Fig. 2026. — Posterior view of mandible, showing a united fracture 
of the neck of the left condyle. _ This position is typical for this class 
of fractures. Through the action of the external pterygoid muscle 
the position of the head of the condyle sometimes interferes with 
the function of the mandibular nerve and vessels. The illustration 
also shows that there has been another fracture between the canine 
tooth and the second incisor, passing through the bone. (Courtesy 
Dr. M. H. Cryer.) 

Of the complications due to infection, the most frequent and im- 
portant is necrosis of the ends of the fragments. This condition may 
lead to delayed union, or pseudo-arthrosis, to abscess, salivary fistula, 
septicaemia, and pyaemia. Stomatitis is also a frequent complication. 



220 



TEEATISE OX FRACTURES 



Fig. 203a. 



Fig. 2036. 




Fig. 203a. — An anterior view of the same skull. The left conch'le is seen in the left pterygomaxillary fossa. 

(Courtesy Dr. M. H. Cryer.) 
Fig. 2036. — Fracture of mandible through base of anterior part of alveolar process. 




Fig. 204. — Method of determining crepitus and abnormal mobility of frag- 
ments in fracture of the mandible. 



Diagnosis. — The diagnosis of fracture of the mandible is, as a rule, 
made without difficulty. In condylar fracture diagnosis may be difficult. 
Usually crepitus may be obtained, and this, combined with the history 
of violence, local tenderness on pressure, the presence of a depression 



feactur.es of the MANDIBLE 221 

anterior to the external meatus, and the failure of the condyle to follow 
the movements of the lower jaw on motion of the latter, will generally 
clear up the diagnosis. In most of the instances the diagnosis may be 
made from deformity, pain on motion, chewing or talking, crepitus, 
profuse salivation often streaked with blood, laceration of the mucosa, 
and localized pain on pressure or motion. Fractures of the coronoid 
process can only be suspected clinically by local tenderness on pressure 
inside the mouth and pain on motion. Crepitus may or may not be 
elicited. Radiograms will solve most cases with great readiness. 

Prognosis. — Union of uncomplicated fractures without extensile 
laceration of the mucous membrane generally occurs within from four 
to six weeks. The prognosis, even in severe injuries, may be ultimately 
good, provided fixation has been properly maintained after early reduc- 
tion of displacement. Proper occlusion of the teeth must be obtained. 
This is frequently difficult because of previous loss of teeth in the maxilla 
or mandible or in both. Extensive and severe open fractures are often 
followed by good results if there has been no loss of substance from the 
original injury or from secondary infection. In open comminuted frac- 
tures delayed union may result for a time, but eventually union may 
occur after the removal or discharge of sequestra. Pseudarthrosis 
is rare, except when necrosis has occurred or much loss of substance 
been sustained from the traumatism. Gunshot fractures of the man- 
dible are particularly prone to result in deformity of the contour of the 
face and to unite with malocclusion of the lower with the upper teeth. 
They are quite liable to be the subject of deformed union or non-union. 
Industrial injuries of the mandibular region are often similar in nature 
to war wounds. Norris reports only two cases of non-union in 150 
fractures; and the statistics of Muhlenberg and Berenger-Feraud show 
that they form only 2 per cent, of all pseudarthroses observed. Many 
of the disturbances referable to the inferior dental nerve are temporary. 
The presence of severe neuralgia, anaesthesia and paralysis are generally 
due to the presence of a blood clot pressing upon the inferior dental nerve, 
rather than to any actual lacerations or bony compression of the nerve. 
When pressure is produced by bony fragments it is generally in fractures 
posterior to the mental foramen. In prolonged symptoms of compres- 
sion relief may be obtained by operative exposure of the nerve. Fractures 
of the condyloid process may be followed by ankylosis of the temporo- 
maxillary joints. In fractures of the coronoid process fibrous union is the 
rule, and there is generally no interference with subsequent mastication. 

Treatment. — Complicated fractures of the mandible are liable to be 
imperfectly treated by general surgeons. They require a special manipu- 
lative skill not usually acquired by physicians or surgeons ; but found in 
many dental surgeons, The mere dentist who has given little attention 
to oral surgery, but has confined his practice to the teeth alone, is also 
likely to be inefficient in treating fractures of the mandible. In the treat- 



222 TEEATISE OX FRACTURES 

merit of fractures of the inferior maxilla, two points should be carefully 
considered. First, the early reduction and retention of the fragments, 
and, second, the care of the mouth. Failure of union may frequently 
be traced to infection from lack of proper oral asepsis. In all cases a 
primary consideration should be avoidance of a stomatitis with its result- 
ing sepsis and necrosis. This is particularly important, as nearly all 
fractures except those of the ramus are open. The utmost care should 
therefore be used to disinfect the mouth and keep it clean. Thorough 
irrigation with a mild antiseptic solution should be performed after 
each meal. 

Reduction of the fragments by pressure of the fingers on the teeth 
is usually easy, though occasionally comminuted fragments or displaced 
teeth may cause interlocking and require removal before correct apposi- 
tion is obtainable. Teeth which are simply loosened should not be re- 
moved unless they prevent proper reduction, or the loose tooth is in the 
line of fracture. In the latter condition it will probably die and, acting 
as a foreign body, prevent union or increase infection. Therefore teeth 
in the fracture line should be removed at the primary dressing. Care 
should be taken to maintain the " bite " — the normal relation of the upper 
and the lower teeth. Union in most cases is fairly firm at the end of three 
weeks, and very little retentive apparatus is required after the fourth week. 
Reduction in fractures of the condyle may generally be obtained by fol- 
lowing the suggestion of Ribes, which consists in first pulling the jaw 
forward and then pressing the condyle from within outward by the finger 
placed upon the upper, lateral wall of the pharynx. Reduction in other 
cases is generally easy. 

Y\ nile reduction is simple, as a rule, its maintenance is often difficult 
or impossible. In some cases the simplest measures will retain the frag- 
ments in their proper position. The various methods of maintaining 
reduction may be grouped as follows : External dressings ; combined ex- 
ternal and internal dressings or splints ; internal splints ; and wiring or some 
other method of direct fixation. In all but the least difficult cases the sur- 
geon will do well to have the advice. and aid of a dental expert, capable of 
making and applying interdental and intermaxillary splints. On the 
other hand, it is not likely that a dentist should have the entire care of 
a fractured mandible ; his experience is seldom such as to make him 
competent to meet successfully the medical and surgical emergencies 
possible in such injuries. 

External Splints. — The simplest form of external dressing is the 
figure-of-8 bandage of the occiput, crown and chin ; or a moulded plaster- 
of -Paris or pasteboard chin splint (Figs. 205 and 206), or a metal chin 
splint held in place with an occipitomental roller bandage or a four-tailed 
scarf. These dressings utilize the upper jaw as a splint. They are efficient 
when there is little tendency to recurrence of displacement and the existing 
teeth of the patient in the two dental arches are such as to give reasonable 



FRACTUKES OF THE MANDIBLE 



223 



immobility by their contact. They are also useful as temporary or emer- 
gency dressings, while an interdental splint is being obtained. 

As a permanent dressing, in the presence of any marked tendency 
toward displacement of fragments, they are not satisfactory. 

Combined External and Internal Splints. — Various dental and inter- 
dental appliances are in use which maintain fixation of the fragments 
by means of vulcanite or metal appliances to the teeth or between the 
jaws and an external figure-of-8 bandage. Two splints are known as 
the Gunning and the Hern modification of the same. The Gunning splint 
consists of two curved vulcanite caps for the teeth, in the upper and lower 
jaws, joined together by supports. After insertion of the splint the man- 



Fig. 205. 




\ - 


- ■'-■-- ;4:V! 


^ 





( 



Fig. 206. 



m 






* jSZ 




Fig. 205. — Moulded felt chin splint padded with several layers of sheet- wadding. 
Fig. 206. — Application of occipitomental roller bandage to hold chin splint in place in fracture of the 

mandible. 



dible is fixed between it, within the mouth, and a figure-of-8 bandage on 
the outside of the chin. 

The Hern modification of the above consists of a vulcanite cap cover- 
ing the teeth and the alveolar border of the inferior maxilla. Blocks or 
pillars are built upon the upper surface of the splint; these contain inden- 
tations corresponding to the upper teeth. The recesses of the vulcanite 
contain gutta-percha for articulation with the upper teeth. The splint 
is applied like the Gunning and is held in place by a skull and chin cap, 
with connecting bands of elastic webbing to produce constant pressure. 

Dr. V. P. Blair, of St. Louis, introduced into the American army a 
modification of the usual intraoral appliances for fractures of the man- 
dible. Into the gutters of two dental impression trays are placed masses 
of modelling composition. This is softened by dipping into warm water ; 
and a filled tray pressed against the upper dental arch so that the teeth 
become imbedded in the softened composition. The other tray is pressed 
down upon the lower teeth while the fragments of the mandible are 



224, 



TEEATISE OX FEACTUBES 



held in proper reduction. In a few moments the dental compound hardens 
and the teeth are firmly imbedded. The two trays are then fastened to 
gether by means of wires attached to them Thus the broken mandible 
with the fragments reduced is firmly fixed and supported against the 
maxillary bones above. 

Interdental Splints and Dressings. — There are many methods of inter- 
maxillary and interdental splinting. The Hammond splint is made by 
bending soft iron wire and moulding it as accurately as possible to a plaster 
model of the teeth made from an impression. The wire is fitted to the 
lingual and buccal sides of the teeth, the ends being soldered together. 
If necessary, the wire may be fitted directly to the teeth. When the 
splint has been made, the fragments are reduced, the splint placed in posi- 
tion, and the teeth fixed to the splint by means of ordinary iron or silver 



Fig. 207. 



Fig. 208. 





Fig. 207. — A fracture of the mandible, showing interdental splint in position. (Courtesy of Dr. M. 

H. Cryer.) 

Fig. 208. — An interdental splint holding the mandible together where a pathological separation of 

bone occurred, causing the loss of a complete section of bone. New bone filled in the parts, leaving 

no disfigurement or shortening of the jaw. (Courtesy of Dr. M. H. Cryer.) 

wire. When there are a number of teeth present those close to the seat 
of fracture should not be bound. After the end of a week the wires should 
be tightened. The splint devised by Claude Martin, of Lyons, is a 
modification of the above and consists of three silver wires approximately 
the form of the dental arch, and which are connected to each other at 
intervals by transverse wires, and is held to the teeth by means of silk 
thread. The Angle splint consists of encircling bands of metal applied to 
several approximating upper and lower teeth. These bands are adjusted 
to the individual teeth, are tightened, and the outer surface of each band 
has a small projection to which wires are attached, joining the upper and 
lower bands and holding fast the upper and lower teeth. The Payne 
splint is made of a silver wire framework fitted to the necks of the upper 
and lower teeth on the labial and lingual aspects, the wire being carried 
around the arch as far as it is necessary. The ends of each half of the 
framework are soldered together and at several intervals transverse bars 
are fixed. The two arches are united by rods on the labial and lingual 



FBACTUE.es OF THE MANDIBLE 225 

sides and the splint ligatured to the teeth by means of fine silver wire. 
The advantages of this splint are that the fragments are held in good 
position, the teeth and mouth can be readily cleansed, and the condition of 
the jaw observed. 

Useful forms of splints for fractures of the mandible are interdental 
splints and mandibulomaxillary splints of varied designs modified to meet 
the exigencies of the cases. Gunshot fractures have within the last four 
years given dental surgeons much experience in treating complicated 
mandibular injuries. Some of these methods have been mentioned in 
connection with fractures of the upper jawbones. The jacket interdental 
splint (Figs. 207-209) is made to fit the crowns of all the lower teeth 
at each side of the seat of fracture. After reduction of the fragments, the 
splint is cemented in place. This splint allows opening and closing' the 



Fig. 209a 




Fig. 209a. — An interdental splint used in case of a compound fracture of the mandible. At first the parts 
were wired together with bad results; the wire was removed and a splint was cemented in position. In 

six weeks' time the parts had united. (Courtesy of Dr. M. H. Cryer.) 

Fig. 2096. — Two compound fractures at the angles of the mandible treated by a mandibulomaxillary 

splint, consisting of two interdental splints, upper and lower, soldered together and cemented so that 

the teeth are held together in their normal position. Although there is no hold of the rami by the splints 

they will adjust themselves to the other end of the bone. (Courtesy of Dr. M. H. Cryer.) 



mouth for inspection. The mandibulomaxillary splint is made of alu- 
minum or gold. It fits the crowns of both the upper and lower teeth, 
and after reduction of the fragments it is cemented to both arches. It 
therefore does not permit the mouth to open, and does not allow masti- 
cation. It is particularly useful in double fracture of the mandible. 

A simple splint for fracture of the body may be made by softening 
a gutta-percha strip in hot water, moulding it to the crowns of the lower 
teeth, so as to overlap the adjacent gum, and hardening it with dipping in 
cold water. Such a splint may be fixed in position by wires carried 
by needles through the muscles and skin of the chin and twisted over 
small rolls of adhesive plaster placed on the skin beneath the lower border 
of the mandible. 

In patients who have lost all or nearly all their teeth, interdental 
15 



226 



TEEATISE OX FEACTTKES 



splints moulded to the atrophied gums offer about the only means of 
maintaining immobility after reduction of the displaced fragment. 

Suture of the fragments with silver wire or silver-plated copper wire 
has been used rather extensively at times. The cases in which this form 
of retention is indicated are limited. Various methods of using wire are 
in vogue. That employed by Gilmer is valuable. It locks the lower and 
upper jaws together by wires twisted around the necks of two opposing 
teeth in each jaw, on both sides of the line of fracture. Perhaps the 




Fig. 210. — Rontgenogram showing method of suture of fragments in fracture of the mandible 

with silver wire. 

simplest is to drill holes in each fragment, at least one-fourth of an inch 
away from the seat of fracture. The hole in the depressed fragment 
should be drilled at a lower level than the one in the other fragment, 
so that in tightening the wire there is a lifting tendency and a great 
resistance to recurrence of deformity. After introducing the wire the 
fragments of bone should be drawn together, the wire twisted and cut, 
and the sharp ends covered by small pieces of rubber tubing. Screws 
or steel plates may be used in a manner similar to that employed in fixa- 
tion of bones of the extremities. They are, however, rarely used. An 
X-shaped aluminum or steel plate may be found available in direct fixa- 



FKACTUBES OF THE MANDIBLE 227 

tion of fracture at the angle of the mandible. For fracture behind the 
first molar with loss of bone substance Pickrell has prevented riding 
upward and outward of the posterior fragment by putting a screw through 
the zygoma into the coronoid process. This retains the fragment in nor- 
mal relation to the rest of the jaw until union has occurred. The screw 
is then taken out. 

In difficult cases of fracture of the lower jaw with displacement of 
fragments, the aid of a competent dental surgeon should be secured in 
the preparation and application of a suitable wiring or interdental splint. 

Summary of Treatment of Fractures of the Mandible 

Fractures of the body with little tendency to displacement, treat with 
an occipitomental figure-of-8 bandage (Barton's), using the upper jaw 
as a splint. A moulded chin splint may be used under the bandage. It 
should extend from one angle of the bone to the other. 

Fractures of the body, rather difficult to keep reduced, treat by wiring 
the teeth of mandible to teeth of maxillae on both sides of the fracture 
line. Be careful to make it possible to> release quickly the wired jaws, 
if vomiting is likely to occur from seasickness 
or anaesthesia. Sometimes wiring two teeth 
on one side of the break to two teeth on the 
other side without fixing the upper and lower 
jaws together may be all that is needed. 

More difficult cases of fractures of the body 
(Fig. 21 1 ) such as comminuted and double 
fractures, treat with a dental or intermaxillary 
splint. The dental splint is fixed to the man- 

1 111 • ™ IG- 2Ilm — Gunnings mtermax- 

dibular teeth onlv by means of wires around illar y splint with opening for 

. feeding. 

the bone and chm or by being cemented to the 

teeth. The intermaxillary is fixed by its indentations to both upper 

and lower teeth. 

After two weeks, in the usual fractures of body, slight attempts 
at mastication may be permitted. This permission may reveal defects in 
occlusion of the teeth which should be remedied at once. Remember, that 
a proper " bite " is essential to chewing food and that the normal relation 
of the upper and lower teeth in most mouths is that upper incisors come in 
front of the lower when the mouth is quietly closed. See that the chin 
will not deviate from the middle line after union of fracture. Mal- 
occlusion of the teeth after treatment of a jaw fracture is apt to lead 
to suit for damages. 

Fractures near the angle of the mandible are likely to need inter- 
maxillary splints, wiring of teeth or operative fixation applied directly to 
the bone through a skin incision. 

Fractures of the condyle and of the coronoid process are rare. They 
may be overlooked unless X-ray examinations are made. 




228 TREATISE OX FEACTUEES 

Fractures complicated by great comminution of the mandible, absence 
of teeth, loss of substance of the bone from necrosis or severe injury, 
delay in treatment, or by severe local sepsis are very difficult surgical 
problems. Gunshot fractures belong in this class. 

In the advent or probable advent of active inflammation at the seat of 
fracture, make an incision through the skin below the mandible and insti- 
tute drainage. Do not be in too great a hurry to remove splinters or 
small fragments of bone. Small pieces of detached bone may unex- 
pectedly survive and aid in reconstructing the dental arch. Even necrotic 
bone often may be left in place until the periosteum has become thickened, 
and new bone formed to give support and lessen the danger of union with 
irregular apposition of teeth. 

Rebellious displacement of the posterior fragment in breaks near the 
angle may be managed with a screw driven through the zygoma into the 
coronoid process. 

Old fractures of the mandible united with deformity causing 
facial disfigurement or faulty articulation of the teeth usually re- 
quire orthodontic or operative correction. Non-union of mandibular 
fractures occurring after great loss of substance, treat by grafting carti- 
lage or bone into gap ; provided that sufficient time has elapsed to make 
it relatively sure that usual methods of dental fixation will not be followed 
by union except with unjustifiable malocclusion of the teeth. Grafting 
should be delayed until the suppuration in infected cases has ceased for 
several months. Otherwise failure is likely to occur. Considerable 
gaps may be firmly closed, with the jaw reconstructed so as to give 
good dental articulation of the teeth in the two dental arches, if expert 
oral surgery has been given the patient. It must be remembered, how- 
ever, that muscular and cicatricial contraction may gradually produce 
a V-shaped mandible, rendering proper mastication impossible, after a 
certain amount of union apparently bony has been obtained. Grafts 
may be taken from rib, tibia, or crest of ilium. A pedunculated flap 
containing the needed bone may be transferred from the sternal end 
of the clavicle. 

Comminuted and infected fractures from industrial accidents, treat 
in the manner advised for gunshot fractures. 



CHAPTER XI 

FRACTURES OF HYOID BONE AND CARTILAGES OF 
LARYNX AND TRACHEA 

Fractures of the Hyoid Bone 

Anatomy.— The hyoid (Fig. 212) or lingual bone is a small horse- 
shoe-shaped bone situated at the base of the tongue between the chin and 
the thyroid cartilage. It consists of a body, two greater cornua, and two 
lesser cornua. The body has a concave posterior surface directed back- 
ward and downward toward the epiglottis. The greater cornua are 
tapering processes arising from the sides of the body, are directed up- 
ward and backward, and end in a small bulbous tubercle to which the 
thyrohyoid ligaments are attached. They may be connected to the 
body by either bony tissue or librocartilage. The lesser cornua arise 
from the bases of the greater cornua, extend upward and backward, 
are at times cartilaginous, are shorter than the greater cornua, and are 
connected with the styloid processes of the temporal bones by the stylo- 
hyoid ligament. 

Surface Markings. — The hyoid bone may be palpated throughout. 
Its position is directly behind the chin. The greater cornu is the land- 
mark for the location of the origins of the superior thyroid, lingual, and 
facial arteries. 

Statistics. — Gurlt's collected statistics of 27 cases showed in 21 cases 
fractures of the bone alone, and in the remaining cases there were asso- 
ciated fractures of the thyroid or cricoid cartilage or of the trachea. 
Of the 13 collected cases reported by Gibbs, 7 followed strangulation, 3 
were the result of a blow or a fall, and 3 were due to muscular action. 

Etiology. — Fractures of the hyoid, owing to its sheltered position, 
its elasticity and mobility, are extremely rare. Fractures are usually 
the result of direct violence as from a blow or fall, pressure of the rope 
in hanging, or grasping the throat (Fig. 213) as in homicidal assaults. 
It has been broken as the result of muscular action. In fractures due 
to direct violence the break usually occurs near the junction of the greater 
horn. Those of the body itself are usually the result of a blow or a kick. 
Fractures of the lesser horn are extremely rare. In hyoid fracture there 
is generally considerable displacement of the fragments; and the injury 
may be associated with fracture of the laryngeal cartilages. 

Symptoms. — The symptoms are localized pain, tenderness, and swell- 
ing in the region of the hyoid, pain on opening the mouth or on pro- 
truding the tongue, painful deglutition, difficulty in talking, dyspnoea, 
occasional oedema of the larynx with its accompanying symptoms, 
local ecchymosis, crepitus, abnormal mobility and displacement of 

229 



230 



TREATISE OX FRACTURES 



fragments, and if the mucous membrane of the pharynx is lacerated, 
bleeding from the mouth. Sometimes the displaced fragment may be 
readily felt with the linger in the pharynx. Coughing, with paroxysms 
of choking or asphyxia, may follow attempts at swallowing or protrud- 
ing the tongue. 

Complications. — The complications of fracture of the hvoid are 
accompanying injuries to the laryngeal cartilages, 
pharyngeal vessels, oedema of the larynx, absces 



hemorrhage from 
and necrosis of 



— Great cornu 



Diagnosis. — The diagnosis can usually be made from the history 
of injury, the presence of crepitus, displacement of fragments, dyspnoea, 
and dysphagia. 

Prognosis. — Simple, uncomplicated fracture of the hyoid should not 
be followed by untoward results. In the presence of laryngeal compli- 
cations death may result from oedema of the glottis. 

Treatment. — Reduction of displaced fragments is as readily accom- 
plished as retention in their 
normal position is difficult. Re- 
placement can generally be 
\% jli made by manipulation with a 

finger in the pharynx, com- 
bined with external pressure. 
The fragments may be retained 
in fair approximation by im- 
mobilization of the head and 
neck by extension and sand 
pillows, or by means of a stiff 
collar. Dyspnoea with develop- 
ment of oedema of the larynx 
will necessitate low tracheotomy, and dysphagia may necessitate the use of 
a stomach tube. Union of fragments in a deformed position or non-union 
may require excision of the displaced fragment. 

Fractures of the Cartilages of the Larynx axd Trachea 

Anatomy. — The larynx is in relation above with the hyoid bone, below 
with the trachea, and is opposite to the lowest three cervical vertebrae. 
It is formed of three single cartilages, the thyroid, the cricoid, and the 
epiglottis, and three or four pairs of smaller cartilages called the arytenoid, 
the corniculate, the cuneiform, and the cartilagines triticae. 

The thyroid is the largest of the laryngeal cartilages and is situated 
above the cricoid cartilage. It presents on each side an ala, and in the 
centre a notch formed by the union of the two ake. On the posterior bor- 
der of each surface there arise the superior and inferior cornua. 

The cricoid is the lowest of the cartilages of the larynx and resembles 
a signet ring. It is connected with the thyroid by the cricohyoid Hga- 




Fig. 212. — The hyoid bone, anterior view. 
Anatomy.) 



mail cornu 



(Piersol's 



FKACTUKES OF HYOID BONE AND CARTILAGES 231 

merits. The other cartilages are unimportant in relation to fractures. 
The trachea or windpipe is a membrano-cartilaginous tube about four 
and a half inches long, situated in the anterior lower part of the neck. 
It lies in front of the oesophagus and extends downward from the lower 
border of the larynx to its termination in the bronchi; this is from the 
level of the sixth cervical to that of the fourth thoracic vertebra. It is 
formed by sixteen to twenty cartilaginous rings, which are open poste- 
riorlv for about one-third to one-fifth of their circumference and are 




Fig. 213. — Fracture of the hyoid bone. Occurred during the extraction of a molar tooth 
while the patient was under nitrous oxide anaesthesia. The dentist pressed on the hyoid 
bone with his hand. Patient complained of hoarseness, but there was no oedema present. 

joined to one another by the annular ligaments. The posterior section of 
the rings is filled by a musculo-fibrous membrane. 

Surface Markings. — The thyroid cartilage of the larynx forms the 
so-called " Adam's apple," in the anterior part of the neck below the 
hyoid bone. It is most prominent in males, is entirely cartilaginous; 
and its body, borders, and cornua can be readily palpated. The cricoid 
cartilage lies immediately below the thyroid cartilage, is seal-ring in shape, 
and can be readily felt with the fingers. The laryngeal cartilages seldom 
ossify even in old age. 

The trachea is situated just below the cricoid cartilage, and about 
one to one and a half inches of its upper end may be examined with the 
fingers. On marked extension of the neck another inch may be palpated. 
The rings of the second, third, and fourth cartilages are generally covered 
by the isthmus of the thyroid gland. The portion just above the sternum 



232 TEEATISE OX FKACTUKES 

is situated rather deeply on account of the recession of the upper cervical 
and thoracic vertebra?. 

Etiology. — The causes of fractures of the cartilages of the larynx 
and trachea are blows, as by balls in cricket or baseball games, falls, hang- 
ing, homicidal throttling, muscular action, and incised and gunshot 
wounds. Fractures are generally produced by lateral compression or by 
anterior pressure directed backward toward the vertebral column. Frac- 
ture-s of the thyroid are usually vertical near the median line, if produced 
by lateral pressure; the lines of fracture, however, may be longitudinal, 
irregular, comminuted, or transverse. Fracture of the cricoid is gener- 
ally bilateral, and a single fracture in the median line is rare. Fractures 
of the arytenoids are generally seen in conjunction with fractures of 
other cartilages. 

Fractures of the trachea are extremely rare and often they go unrecog- 
nized before death. Brigel has reported 33 cases and Hoffmann has 
added 12 more cases. The causes of fractures of the trachea are the 
same as those of fracture of the larynx. In addition may be mentioned 
overstretching of the trachea in upper part of the chest. In Hoff- 
mann's reported statistics were children affected in 13 cases; and in 
17 cases the fractures were associated with fracture of the larynx or 
of the hyoid. There were complicating injuries of the ribs or sternum 
in 19 cases. 

Symptoms. — The symptoms of fracture of the cartilages of the larynx 
are deformity, abnormal mobility, cartilage crepitus accompanied by a 
convulsive cough, alteration in or loss of voice, dyspnoea, dysphagia, often 
blood-streaked sputum, and in many cases emphysema extending over the 
neck, face and trunk. Interference with respiration may not be pro- 
nounced at first: but it is generally progressive, so that after a time there 
are stridor, cyanosis, marked dyspnoea and the development of a rapid 
pulse and evidences of respiratory failure. The interference of respiration 
may be due to oedema of or hemorrhage into the mucous membrane, dis- 
location of fragments, or the closure of the calibre of the larynx or trachea 
by cellular emphysema. In severe cases death may be due to suffocation 
from subcutaneous hemorrhage, to free bleeding into the larynx, or to 
inflammatory or emphysematous swelling. 

In fractures of the trachea the subjective symptoms differ little from 
those seen in fractures of the larynx. There may be. in addition, how- 
ever, gurgling and tracheal rales, and marked dyspnoea in the beginning. 
The classical symptoms of fracture, crepitus and abnormal mobility, are 
generally impossible of demonstration. 

Complications. — The complications of fracture of the cartilages of 
the larynx and trachea are oedema and hemorrhage within or around the 
larynx or trachea. 

Diagnosis. — The diagnosis of fractures of the cartilages of the larynx 
can generally be made by the history of the case, the evidences of external 



FKACTUEES OF HYOID BONE AND CARTILAGES 233 

injury, and the results of laryngoscopic examination. In the early stages 
there may be oedema, or hemorrhagic extravasation, circumscribed or 
diffuse, discovered by laryngoscopic examination. If these conditions are 
excessive it may be impossible to make a thorough examination. 

In fractures of the trachea the diagnosis will be determined largely by 
the presence of associated injuries to the larynx and the intrathoracic 
symptoms of compression. 

Prognosis. — In all fractures of the cartilages of the larynx and trachea 
the prognosis is very grave, although not so grave as formerly was sup- 
posed. This is shown by the statistics of Hoffmann. Of the 75 re- 
ported cases prior to 1879 there were 16 recoveries and 59 deaths; of the 
cases since that year there were 40 recoveries and 26 deaths. In many 
of the fatal cases death may occur soon after the accident; but it may be 
delayed for several days. Death in nearly all cases is due to oedema 
of the glottis, to the displacement of fragments, to the inspiration of 
blood, to mediastinal emphysema, or to secondary hemorrhage. Other 
causes of death are septicaemia and aspiration pneumonia. 

Treatment. — The primary indication in treatment of laryngeal frac- 
tures is to maintain a free current of air to and from the lungs. For this 
purpose tracheotomy is necessary in a large majority of cases. If there 
is any evidence of oedema of the glottis or intralaryngeal hemorrhage, or 
a tendency to displacement of fragments, or to dyspnoea or emphysema, 
a tracheotomy should be performed. The onset of partial or com- 
plete obstruction may be very sudden, and unless measures are 
at hand to promptly perform a tracheotomy, death may occur before 
relief can be given. Some authorities even go so far as to state that 
a tracheotomy should be performed as soon as a diagnosis has been made. 
If, however, there are no distressing symptoms, if the patient is in a hos- 
pital and has the constant attendance of a surgeon with all the necessary 
instruments at hand, a tracheotomy may be delayed. In addition to the 
above procedure one should endeavor to keep the patient quiet, replacing" 
fragments when possible, keeping the parts aseptic, and preventing subse- 
quent hemorrhage. It is possible that laryngeal intubation might be wise 
in some cases of fracture in which the more radical laryngectomy or 
tracheotomy might be deemed undesirable. In times of doubt, operation 
for securing adequate admission of air to the patient's lungs should not 
be delayed. Sudden asphyxia may cause death before aid is secured. 
The performance of tracheotomy and use of opiates should be the primary 
course of treatment. Later indications for surgical intervention should 
be met as they arise. In fractures of the trachea, tracheotomy is always 
indicated, and a tube large enough to go beyond the seat of fracture 
should be used. 



CHAPTER XII 

FRACTURES OF THE VERTEBRAE 

Anatomy. — The vertebral column or spine (Fig. 214), composed of 
a series of vertebrae, is the central part of the skeleton, and is in the 
median line posteriorly. It supports the head above, the ribs on each 
side, and, through the latter, the upper extremities. It transmits the 
weight of the body through the pelvic bones to the lower extremities. It 
surrounds the spinal cord and affords exits for the spinal nerves. The 
vertebral column consists of from 32 to 35 vertebrae; of these 24 are 
true vertebrae, and 8 to 1 1 false vertebrae. The true or movable vertebrae 
may be divided as follows : 7 cervical, 12 dorsal or thoracic, and 5 lumbar 
vertebrae. The false vertebrae vary in number and form two bones, the 
sacrum and the coccyx. The typical vertebra is composed of a body, 
a neural arch behind, forming with the body the spinal foramen, and a 
number of processes. The neural arch is formed by two halves, and con- 
sists of two pedicles and two laminae which support seven processes, four 
articular, two transverse, and one spinous. Sometimes additional rudi- 
mentary ribs are found attached to the lower cervical vertebrae. This 
must not be forgotten in X-ray studies of vertebral fractures. There is 
occasionally a numerical variation in the number of movable vertebrae. 

A vertebra is developed from three primary ossific centres, one for the 
body and one for each side of the neural arch and its processes. The first 
and second cervical vertebrae differ from the remaining true vertebrae. 
The atlas or first cervical vertebra has no body or spinous process, is 
formed of a ventral and dorsal arch and two lateral masses. The body 
may be represented by the odontoid process of the axis. The axis or 
second cervical vertebra is characterized by a large, strong body and 
a large process arising from the superior surface of the body called the 
odontoid process. The atlas rotates around this process as a pivot, and 
with it the head also rotates. 

The sacrum is formed early in life of five segments, which later be- 
come fused to form one bone, the os sacrum. It articulates above with the 
fifth lumbar vertebra, below with the coccyx, and laterally with the two 
innominate or hip-bones, forming with the last the pelvic girdle. 

The coccyx is composed of from three to five, usually four, rudimen- 
tary vertebrae, fused together and tapering from above downward. In 
early life, especially in the female, they may be movable upon one another 
and upon the sacrum. Later in life, the joints between the coccygeal 
elements themselves and that between the first part of the coccyx and the 
sacrum become ankylosed. 
234 



FBACTUEES OF THE VERTEBRAE 



235 



1. Cervical (atlas) 



V—* 1 . Thoracic 



On viewing the spinal column laterally, it will be noted that there 
are four curves. In the cervical and lumbar regions the curves are convex 
forward, in the thoracic and sacral regions the curves are convex back- 
ward. The thoracic and sacral curves are primary, are found in the 
embryo, and are for the accommodation of 
the thoracic and pelvic viscera. The cervical 
and lumbar curves, being compensatory, are 
secondary and are developed later in life. The 
weakest part of the vertebral column is at the 
junction of the second and third cervical ver- 
tebra?. The vertebra? most subject to fracture, 
however, are from the tenth thoracic to the 
second lumbar vertebra?. This is because at 
that point the fixed thoracic part meets the 
most movable part of the lumbar region, 
giving great leverage during movement, and 
the lateral processes are not so marked as 
above and below. 

The vertebral column is completed by its 
ligamentous attachments and by the interver- 
tebral disks situated between the bodies of the 
vertebra?. The ligaments are : The anterior 
longitudinal ligament, which begins at the 
pharyngeal tubercle at the base of the skull 
and terminates on the anterior surface of the 
sacrum. It is firmly attached to the anterior 
surface of the bodies of the vertebra? and in- 
timately connected with the intervertebral 
fibrocartilages and laterally with the perios- 
teum of the bodies. 

The posterior longitudinal ligament begins 
at the second cervical vertebra and terminates 
in the sacral canal. It is attached to the pos- 
terior surfaces of the bodies of the vertebra?. 

The second group of ligaments connect 
adjoining vertebra? to each other, and may be 
divided into those connecting the arches and 
those joining the processes. They are the 
following: Ligamenta flava between the ver- 
tebral arches; intertransverse ligaments, connecting the transverse 
processes of the vertebra?; interspinous ligaments, connecting the spinous 
processes of contiguous vertebra? ; supraspinous ligaments, connecting the 
apices of the spinous processes; ligamentum nucha?, running from the 
spinous process of the seventh cervical vertebra to the external occipi- 
tal protuberance. 



m 



* ' "\— -1. Lumbar 



m 



1 



f— 1. Sacral 



1. Coccygeal 



FlG. 214. — Adult spine, lateral view. 
(Piersol's Anatomy). 



23G 



TREATISE OX FEACTTKES 



The articulation of the sacrum with the coccyx is formed by the 
anterior sacrococcygeal, the lateral sacrococcygeal, the posterior coccygeal, 
the superficial posterior sacrococcygeal and deep sacrococcygeal ligaments. 

One of the most important ligaments of the spinal column is the 
transverse ligament of the atlas: which divides the spinal foramen of 
the atlas into two portions, and holds in place the odontoid process 
of the axis posteriorly. This prevents the odontoid process compressing 
the medulla, by dislocation, during rotary movements of the skull and 
atlas upon the second vertebra, which is the axis of movement. Rupture 
of this ligament, as an associate of vertebral fracture or luxation, might 
cause immediate death from pressure upon the vital centres in the 
medulla oblongata. 

Surface Markings. — Extending in the middle line of the back from 



Fig. 215. 



Fig. 216. 




Figs. 215 and 



-Method of palpation through the mouth of the anterior surface of the bodies of 
the upper cervical vertebrae. (.Modified after Cott:n. 



the skull downward to the sacrum there is a furrow, well marked in mus- 
cular individuals. Above it is called the nuchal furrow, below the spinal 
furrow. The spinous processes may be felt at the bottom of this fur- 
row from the atlas to the sacrum. In thin persons there is no furrow, 
but a ridge running down the centre of the back due to the successive 
spinous processes. The dorsal and lumbar spines are more readily pal- 
pable on marked flexion of the spine. Normally there are four antero- 
posterior curves. The cervical and lumbar are convex forward, the tho- 
racic and sacral are concave forward. Normally there are no lateral 
curves to the spinal column. The position of the posterior superior spine 
of the ilium on each side of the lumbar region of the back is marked by 
a depression at a point just above and external to the third sacral vertebra. 
The spines of the vertebrae may be used in locating various structures. 
The bodies of the first four cervical vertebra? may be palpated through 
the mouth (Figs. 21; and 216V and the bodies of the lumbar vertebrae 



FKACTTKES OF THE VERTEBILE 



237 



may be palpated through the abdomen in very thin or emaciated individ- 
uals, and the coccyx through the anus (Fig. 217). 

Etiology. — Fractures of the spine are observed generally in men, in 
adult life, and especially in those whose occupation exposes them to the 
severe injuries that are required to produce fracture of the vertebrae. 
Women are rarely affected, as are also children under sixteen years, and 
spinal fracture is rarely seen in those of advanced life. The so-called 
" broken back " of children is, as is well known to physicians, a giving way 
of the spine from tubercular softening. A sudden deformity from tuber- 
culosis spondylitis may follow a slight injury and be mistaken for a 
traumatic fracture. Such an incident is not a true fracture. It may, 
however, be classed as a " pathological " fracture when it happens thus 
unexpectedly in a previously un- 
known tubercular softening of the 
vertebral bodies or laminae. Frac- 
tures are the result of direct or in- 
direct force and rarely of muscular 
action. The most frequent cause 
of vertebral fracture is an indirect 
force which tends to produce hyper- 
extension or hyperflexion of the 
spine's normal curves ; hyperflexion 
is the more frequent. Such trau- 
matism occurs in a fall upon the 
head or shoulders, a fall from a 
height upon the buttocks, a crush 
under a weight falling from above 
upon the head or shoulders, or being jammed under a low arch when 
sitting on a car or wagon. Fracture results because the limit 
of flexion or extension has been exceeded and the bony segments are 
crushed or lacerated by the force. The fracture in such instances usually 
occurs where a movable portion of the spine joins a more rigid portion, 
because it is at this point that the sudden check to movement occurs. 
Hence, clinical experience shows that fractures of the vertebrae are most 
frequent near the dorsolumbar junction and in the vicinity of the cervico- 
dorsal region. 

Fractures occurring from direct violence are generally due to the 
striking of the back upon a projecting object, or to a falling object 
striking the back while the patient is stooping over. Fractures by muscu- 
lar action are rare, but cases have been recorded in which this has occurred, 
as in diving. Most fractures received in diving are due to impact of the 
head on the bottom in shallow waters acting as do falls on the head or 
shoulders. The sudden throwing back of the head in order to avoid a 
shallow bottom has been ascribed as sufficient to cause fracture with 
dislocation of the cervical vertebrae. Wrestling has been the cause of 




Fig. 217. — Method of palpation of the coccyx 
through the anus. (Modified after Cotton.) 



!38 



TREATISE OX FRACTURES 



spinal fracture or dislocation by overflexion or overextension at the 
hands of an opponent. 

The bodies of the vertebrae seem to be involved more frequently 
in the lower than in the upper region, while the arches are more frequently 
fractured in the cervical region than elsewhere. Fracture of the spinous 
processes occurs most often in the dorsal region. The lines of fracture 
and the number of vertebrae involved depend upon the direction and the 
degree of the force. 

Fracture is often accompanied by dislocation, and in many cases 
the two conditions are indistinguishable except by radiologic study at 
autopsy. Fracture of two or more vertebrae is common in the cervical 
and upper dorsal regions, less common in the lower dorsal and rare in 
the lumbar region. 

Varieties of Fracture. — Kocher describes the following varieties of 

vertebral fracture : isolated fracture of 
the bodies; isolated fracture of arches, 
spinous processes and transverse proc- 
esses ; and fracture-dislocations. 

Isolated Fracture of the Bodies of 
the Vertebrae (Figs. 218-223). — These 
fractures are always the result of com- 
pression. They are produced by a force 
acting in the long axis of the spine, in 
those portions of the column which have 
a supporting function, namely, the 
anterior column of the vertebral bodies, 
the intervertebral disks, and the double 
column of articular processes. When 
a compressing force is acting in the 
longitudinal axes of the spine, there 
results, first, shortening of the 
articulation processes behind, flexion and compression of the vertebral 
bodies and intervertebral disks until the limit of their elasticity is reached, 
when compression fracture of the bodies of the vertebrae occurs, and, 
in addition, fractures of the intervertebral disks. Compression fractures 
are found most often where the flexibility of the spine is the least. In 
the cervical region flexibility is the greatest and in the dorsal and upper 
lumbar regions it is very limited. In the region where flexibility is 
greatest the intervertebral disks are found to be relatively thickest in 
comparison with the thickness of the vertebral bodies. The relative 
thickness of the disks is greatest in the cervical region; and the thickness 
of both bodies and disks increases from above downward. Compression 
fractures of the bodies of the vertebrae are most frequently seen in the 
dorsal and upper lumbar regions, and least frequently seen in the upper 




Fig. 218. — Compression fracture of the body 
of the fourth dorsal vertebra (Kocher). 



FRACTURES OF THE VERTEBRAE 



239 



third of the dorsal and lower lumbar regions. Kocher found, in a study 
of 2$ isolated fractures of the bodies of the vertebra?, that the lesion had 
occurred from the eighth to the twelfth dorsal vertebra, 1 1 times, and 
the lumbar vertebrae, 7 times ; and that the twelfth dorsal and first lumbar 
vertebrae were involved 5 times. 

In compression fractures of the bodies of the vertebra, the bodies 
of one or more vertebrae are compressed or flattened out, the shape of 
the body is changed by the compressing force to a wedge-shaped mass, 
the crushed portion of the body becomes more dense, and as the vertical 



Fig. 219. 



Fig. 220. 



Fig. 221. 




Fig. 219. — Last thre Q dorsal and first lumbar vertebras. Fracture of the body of the twelfth dorsal. 
The body of the twelfth dorsal is crushed by pressure from above. The anterior border of the superior 
articulating surface is destroyed. From a man who was crushed by the fall of a bank of earth. The 
man died instantly upon being turned in bed while in the hospital. (Mutter Museum, No. 1188.30.) 
Fig. 220. — Ninth, tenth, eleventh and twelfth dorsal, and first two lumbar vertebrae. Fracture of 
the last dorsal. Recent. The first lumbar is fractured by force vertically applied. The compact 
tissue of the body is forced forward and outward in sections, vertical fissures being seen at four places. 
The vertebral canal has been exposed on the left side and shows a fracture of the right lamina. 

(Mutter Museum, No. 1188.40.) 
Fig. 221. — Eleventh and twelfth dorsal and first lumbar vertebrae. Vertical fracture of the twelfth 
dorsal and crescentic fracture of the upper and anterior lip of the first lumbar. Recent. The last dorsal 
is severely crushed. On the left the body is fissured transversely at the middle. The vertical force has 
fractured the first lumbar vertebra at the anterior margin. The patient did not survive the accident 
long. (Mutter Museum, No. 1188.20.) 



diameter is diminished, the horizontal diameter is increased. In other 
less typical cases, fragments may be broken out of the upper anterior 
edge of the body, and are produced by the upward pressure of the anterior 
lower margin of the compressing vertebrae (anterior wedge fragments). 
In addition there is sometimes a crushing out posteriorly into the vertebral 
canal of fragments of bone (posterior wedge fragments) . If the violence 
is severe or prolonged, dislocation of the articular processes may occur as 
a result of the compression and hyperflexion. In addition to the bony 
lesions there may be fracture of the intervertebral disks, and rupture of 
the posterior longitudinal ligament. 

When flexion is combined with abduction, the crushing of the body 



24:0 



TEEATISE OX FEACTUEES 




Fig. 222. — Old compression fracture of bodies of second, third, and fourth 

cervical vertebrae. Woman, twenty-eight years of age, fell down, striking head, 

ten years previously. 




FlG. 223.— Fracture of body of fifth cervical vertebras. Patient 

injured while turning a handspring, landing on head instead of on 

hands, 



FBACTUEES OF THE VERTEBRA 



241 



may take place on one side more than on the other. As a result of the 
compression of the vertebrae there is a tilting up of the spinous process 
of the vertebrae above, so that there is a kyphosis produced in the dorsal 
region and obliteration of the curves in the lumbar region. When more 
than one vertebral body is involved, the kyphosis may be more marked 
or more rounded. 

Isolated Fractures of the Arches, Spinous Processes, and Transverse 
Processes of the Vertebras (Figs. 225-228). — These fractures are rare 



Fig. 224-. — Dislocation of cervical vertebra. 



and when seen are generally the result of great direct violence, or are 
accompanied by dislocation. 

Fractures by muscular action are rare, although a fracture of a spinous 
process the result of muscular action has been reported by Terrier. Frac- 
tures of the arches are generally the result of direct violence applied to 
the spinous processes; and the lamella of one or both sides may be frac- 
tured. The loose fragments may be driven into the cord or cause con- 
siderable pressure upon it. A fracturing force severe enough to fracture 
the arch may produce injury to several adjoining arches. Fractures of 
the arches are more common in the cervical region, and the atlas and 
axis are the vertebrae most frequently involved. 

Isolated fractures of the spinous or transverse processes are most 
16 



242 



TREATISE OX FRACTURES 

Fig. 226. 



Fig. 225. 





Fig. 225. — Diagram to show types of isolated fracture of the arches, spinous and transverse 

processes of the vertebrae. 
Fig. 226. — Six lower cervical vertebrae. Fracture of the left lamina and pedicle of the fourth and 
of the laminae of the fifth cervical vertebrae. Recent. The fracture of the fourth vertebra passes 
through the lamina, through the articular surface, and through the pedicle. The fifth vertebra 
is fractured through both laminae, completely detaching the spinous process. A hod-carrier, a 
man aged thirty-two years, fell on the round of a ladder. Death occurred six hours after the 
accident. Both respiration and heart action were labored. The phrenic nerve was pressed on 
by a clot of blood; and the spinal cord at the level of the fourth cervical vertebra appeared con- 
gested. (Mutter Museum, No. 1188.) 



Fig. 227. 



Fig. 228. 




Fig. 227. — Compression fracture of fourth and fifth cervical vertebras. 
FlG. 228. — Fracture of lateral processes of the fifth and sixth cervical vertebrae, left side. 



FEACTUEES OF THE YEETEBEiE 



243 



frequently seen in the dorsal region and are the result of direct violence. 
The separated process may be displaced anteriorly between two' vertebrae 
and into the cord, although this condition is rare because the attached liga- 
ments and muscles usually prevent any considerable displacement. 

Fracture-Dislocation of the Vertebrae (Figs. 229-233). — Dislocation 
with fracture of the vertebrae occurs in many forms. In an exaggerated 
compression fracture of the body of a vertebra associated with dislocation, 
the compressed vertebra becomes wedge-shaped, the upper surface slant- 
ing, and dislocation of the vertebra above may take place downward 
and forward. This injury is generally produced by compression from 
above downward, combined with flexion. In dislocation combined with 
a diagonal fracture, the 
line of fracture may in- 
volve either the lower pos- 
terior portion of the dis- 
located vertebra, so that a 
portion of the fractured 
and dislocated body re- 
mains in its normal po- 
sition, or it may involve 
not only the dislocated 
vertebra, but also the an- 
terior superior portion of 
the vertebra below. In the 
latter case the fragment 
of the lower vertebra is 
carried forward and 
downward along with the 
dislocated vertebrae and 
a part of the interverte- 
bral disk. In this injury 

the line of fracture involves two vertebrae and extends from behind and 
above downward and forward. The displacement in fracture-dislocations 
is so great at times that the dislocated vertebra lies on the anterior surface 
of the vertebra below. Dislocation of the upper vertebra forward and 
downward, combined Avith fracture of the articular processes, sometimes 
takes place. This condition so closely resembles an ordinary forward dislo- 
cation without fracture that it is almost impossible to differentiate it 
clinically except by examination with X-rays. 

Atypical deviations of the three mentioned forms of fracture-dislo- 
cation are very rare. Kocher describes two cases in which there were 
unilateral joint dislocations associated with fracture of the body in a 
downward and outward direction. Complete dislocation backward com- 
bined with fracture due to hyperextension of the neck has been reported; 
and Kocher and Wagner-Stolper mention cases of backward dislocation 
with fracture in the dorsal region. 




Fig. 229. — Dislocation of sixth cervical vertebra (Kocher). 



2U 



TEEATISE OX FEACTUKES 



Kocher believes that there are three forms of force operating in 
these fracture-dislocations : compressions from above downward, hyper- 
flexion, and direct force. To produce the injury, one or all of them may 
be acting. He considers that this accounts for the relative frequency of 
dislocation with diagonal fractures in the dorsal region, because com- 
pression acting upon a normally flexed portion of the spine increases the 
flexion. They are rare in the lower dorsal and lumbar region on account 
of the normal lordosis, whereas isolated compression fractures of the 



Fig. 230. 



Fig. 231. 




Fig. 230. — The lower dorsal and four upper lumbar vertebrae, with portions of 
the three lower ribs of both sides. Fracture of the twelfth dorsal and first lumbar 
vertebrae. Partial repair. The bodies of the two fractured vertebrae are com- 
pressed and have coalesced. The intervertebral disk between them has disap- 
peared, and pressure has forced these vertebrae backward, so as to obliterate the 
vertebral canal. The loss of substance anteriorly has allowed the column above 
to bend forward 40 degrees. The vertebral column is fixed in this position by 

permanent callus. (Mutter Museum, Xo. 1 188. 10.) 
Fig. 231. — Cervical vertebrae; luxation of the atlas. The atlas has left its articu- 
lation with the axis and their axes vary 45 degrees. The transverse ligament and 
the ligament binding the first two vertebrae at the posterior portion of the canal 
were subjected to great violence. Removed from the body of a man who com- 
mitted suicide by hanging. While recovering from an attack of mania a potu, 
he used a silk handkerchief around his neck and standing by a gas-pipe, had, 
after attaching handkerchief, jumped up. He was found suspended by the neck 
with his feet on the floor. Death ensued immediately. The spinal cord was 

completely severed. (Mutter Museum, No. 1187.) 



bodies of the vertebra and dislocation-compression fractures are more 
common in this region. 

Of especial importance are the fracture-dislocations occurring in the 
two upper cervical vertebrae. Fractures of the atlas may occur in its 
anterior or posterior arches, with or without dislocation of the anterior 
fragment and the head. Displacement generally takes place and is for- 
ward. In fracture of the odontoid process of the axis the process may 
be carried forward with the atlas even if the transverse ligament is not 
ruptured. Symptoms of pressure upon the cord do not take place unless 



FBACTUBES OF THE YEBTEBB^E 



245 



dislocation occurs. These symptoms may be deferred for months, as in 
the six cases reported by Coste, Kuster and Phillips. 

Wood- Jones from an examination of five sets of vertebras obtained 
from bodies the result of judicial hanging, in which the knot was placed 
a little to the left of the chin, has found a fracture-dislocation of the 
axis vertebra, consisting in a separation of the arch of the vertebra from 




Fig. 232. — Fracture-dislocation of fourth cervical vertebra. Symptoms: referred pain to 
base of neck, right side; some limitation of motion. No evidence of pressure symptoms. 

Recovery. 

its body. In these cases the odontoid process played no part in producing 
death, but the posterior arch of the axis was broken clean off and re- 
mained fixed to the third vertebra, while the atlas, the odontoid process, 
and anterior arch of the axis remained fixed to the skull. This lesion 
is produced by the violent jerk which throws the man's head suddenly 
backward and produces a fracture of the axis. In this series death was 
instantaneous, as the spinal cord was cleanly severed. 

The usual form of dislocation fracture of the upper cervical vertebrae 



24:6 



TREATISE OX FEACTUEES 



is due generally to a fall upon the head or the falling of a weight upon 
the head while the neck is in a flexed position. Direct violence in the 
back of the neck may, rarely, be the etiologic factor. 

Symptoms. — There is often no noticeable deformity, preternatural 
mobility, or crepitus. Diagnosis must then depend uopn the rational symp- 
toms and X-ray study. Many symptoms are referable to lesions, primary 
or secondary, of the spinal marrow. Fractures of the vertebrae derive their 
chief importance from the damage to the spinal cord and nerve-trunks, 



\ 




. ^^ 




Fig. 233. — Fracture-dislocation of bodies of eighth and ninth thoracic vertebras. 

which so often accompanies them. The spinal column may be said to 
have as functions : support to the trunk, upper extremities and head ; 
flexion, extension and rotation; and protection to the spinal cord which 
is essential to life and health. The symptoms may therefore be divided 
into those associated with the fracture itself, and those due to injury 
to the spinal cord and nerve roots. In addition there are certain special 
symptoms which may attend fractures at different levels. 

Symptoms Associated with the Fracture Itself. — Shock. — There is 
frequently evidence of shock present for a time after the accident. In- 



FRACTURES OF THE VERTEBRAE 247 

telligence is, however, unimpaired, except, perhaps, during the initial 
stage of shock. 

Deformity. — There may be in vertebral fractures no noticeable de- 
formity. In most cases, however, there is deformity present. This is 
dependent upon the site of fracture, upon the form of fracture, and also 
upon the presence or absence of dislocation. In fractures in the cervical 
and lumbar regions the normal concavity is decreased, obliterated, or 
replaced by a kyphosis, while in the dorsal region the normal convexity 
may be increased or sharply accentuated at or near the seat of fracture. 
The most common type of deformity in the latter region is a marked 
kyphosis, caused by the spine of the vertebra above the one fractured, or if 
associated with a dislocation by the vertebra broken. An obliteration 
of the normal cervical or lumbar concavity or an accentuation of the 
dorsal convexity in cases of fracture usually, points to a compression 
fracture alone or to a diagonal fracture of one or two vertebrae with 
or without a dislocation. The site of injury may be recognized by the 
prominence of the spinous processes. In fracture-dislocations of the 
upper four cervical vertebrae the deformity may best be recognized by 
palpation through the pharynx. In isolated fractures of the spinous or 
transverse processes or arches there may be no deformity unless the 
fracture is accompanied by a dislocation of fragments. In this case there 
may be lateral deviation of the spinous processes. 

Muscular Spasm. — The muscles about the seat of fracture are 
generally at first in a state of rigidity, and attempts at movement usually 
increase this rigidity, so that fixation of the neck or back occurs at the 
seat of injury. 

Pain. — This is generally present at the seat of fracture. It is 
increased by movement, active or passive, and by local pressure. It may 
be absent. 

Swelling. — Near the seat of fracture there may be found some 
swelling, and after a few days this may be accompanied by ecchymosis. 
These symptoms are, however, variable. Extravasation of blood into the 
cellular tissue in front of and around the spinal column often occurs; and 
after a time may appear upon the surface of the face, chin, neck, and 
other regions. 

Mobility. — Unusual mobility may be observed at times, especially 
in fractures of the cervical region, and occasionally movable regions may 
become more or less immobile, due to spastic contracture of the 
muscles at the seat of fracture or because of the interlocking of 
dislocated fragments. 

Crepitus. — This may be present, absent, or only discernible by the 
patient. In fractures of the spinous process crepitus can generally be 
readily elicited. In other forms of fracture, movements to obtain crepitus 
should not be attempted, as such motions may further increase the dis- 
location of fragments and cause injury to the spinal cord. 



248 



TREATISE OX FRACTURES 




w— ^ to rectus lateralis 

11 to rectus antic, minor 

Anastomosis with hypoglossal 

Anastomosis with pneumogastric 

N. to rectus antic.major 

N. to mastoid region 

Great auricular n. 
Transverse cervical u. 
=^Fi==| N- to Trapezius, Ang. Scap. and Rhomboid 



Supra clavicular n. 

~ Supra-acrotnial n. 

— Phrenie n. 

N. to levator ang scap. 

M. to rhomboid 

Subscapular n. 

_ ^.^Subclavicular n. 



N. to peetoralis major. 



Circumflex n. 

Musculocutaneous n. 

Median n. 

Radial n. 
Ulnar n. 

Internal cutaneous n. 
L,— — — —-.Small internal cutaneous n» 



...TtiO'hypogastric n. 
.lliO'inguinal n. 



External cutaneous n. 
—Genito-crural n. 



Anterior crural ;u 
Obturator n. 



N. to levator ani -»____r<a_v_ 

N.'ta obturator int. --sTL 

N.' to ophincter ani 

Coccygeal n.^. „„. __ 

Co.l 



Superior gluteal n. 



— —.A', to pyriformis 
A T . to gemellus super. 

k »„»«i M to gemellus infer. 
L «.___#. to guadratus 

1 Small sciatic n. 



Fig. 234.— The relation of the segments of the spinal cord and their nerve-roots to the bodies and spines 
of the vertebras. (Starr, from Dejerine et Thomas, Mai. d. 1. Moelle Epiniere, Paris, 1902.) 



FBACTUEES OF THE YEKTEBB^E 



249 



Symptoms Due to Injury of the Spinal Cord and Nerve-roots. — Of 

far greater importance than the damage to the vertebras themselves is 
the injury to the spinal cord and nerve-roots. Lesions the result of the 
fracture or dislocation of the vertebras may be compression, contusion, 
laceration, puncture, and even complete section of the spinal cord. Actual 
pinching by the fragments requires a considerable displacement of bone, 
because the vertebral canal is much larger than the contained cord and 
membranes. Return of fragments to their normal relations may occur 
after the injury to the cord, and the actual amount of immediate traumatic 
displacement not be evident at operation or necropsy. Hemorrhage about 
or into the spinal cord or nerve-roots, effusion about the cord, and later 
pressure from callus formation or degenerative changes in the cord itself 
may result from spinal fractures. The symptoms are dependent upon 
the extent and position of the injur} 7 . The symp- 
toms present generally indicate the height and 
nature of the lesion (Fig. 234). The important 
symptoms may be grouped under disturbances of 
motion, of sensation, of reflexes, and vasomotor 
and trophic changes. The posture assumed by the 
patient in bed is often of great importance. 

Posture of Patient in Bed. — The posture of 
the patient in bed after injury to the spinal cord 
varies with the location of the injury. This is due 
to the fact that the muscles controlled at or below 
the lesion will be paralyzed, and those controlled 
by the cells just above the lesion will be in a state 
of contraction due to the irritation into which their 
motor centres are thrown. If two centres of op- 
posing action are involved, the stronger will be the 
predominant one, so that a position once assumed 
will be fixed and cannot be overcome involuntarily, 
assumed in various lesions are as follows : 

Fifth Cervical Segment. — All motion is impossible, the arms are 
extended and relaxed. 

Sixth Cervical Segment. — Arms abducted, forearms supinated, wrists 
and fingers paralyzed (Fig. 236a). 

Seventh Cervical Segment. — Forearms partially flexed, lie upon the 
body, hands pronated. Voluntary movements at wrist impossible ; move- 
ments of shoulder and elbow can be made (Fig. 236b). 

First Dorsal Segment. — Hands in position resemble a claw (main 
en griff e) ; shoulders and elbows freely movable. 

Second to Tzuelfth Dorsal Segments. — Paralysis of lower extremities, 
no tendency to foot-drop, moderate resistance of the lower limbs to passive 
motion, tendon reflexes are exaggerated and muscles moderately rigid, 
unless there is complete destruction of the cord, when the muscles will be 
relaxed and tendon reflexes lost. 




Fig. 235. — Fracture of fourth 
and fifth dorsal vertebras, 
with marked compression of 
spinal cord, caused by fall 
from a great height. 



The positions 



250 



TREATISE OX FRACTURES 



Entire Lumbar Segments. — Thighs, legs and feet extended, and 
voluntary movement impossible. 

Lower Half of Lumbar Segments. — Thighs drawn up, legs flexed, 
unable to straighten legs or lift foot. 

Sacral Segments. — Feet in extended position, foot-drop, unable to 
move feet or ankles, thighs and knees may be voluntarilv moved. 

Motor Paralysis. — In injury to the spinal cord due to fractures 

Fig. 236c. 



|P 





Fig. 236b. 




Fig. 236a. — Position in lesion of spine between the fifth and sixth cervical 
vertebrae. The elbows are flexed and shoulders abducted. The position is 

due to paralysis of the subscapularis. (After Thorburn.) 

Fig. 236b. — Position in luxation of the sixth and seventh cervical vertebra?. 

The centre for the subscapularis is not involved. (After Kocher.) 



or dislocations, the cord may be partially or completely severed. When 
only partial lesions are present, the symptoms will be entirely different 
from those manifested in complete disintegration of the cord. When 
there is a complete transverse division or destruction of the cord, there 
will be complete paralysis below the level of the lesion, the limbs will 
be relaxed and flaccid, the paralysis symmetrical on both sides, and there 
will be complete loss of all tendon reflexes. In partial lesions of the cord 



FRACTURES OF THE VEBTEBILE 



251 



there may be total paralysis below the level of the injury, with a condition 
of rigidity of the lower limbs and an increase of the tendon reflexes, 
W 'hen the cord sustains damage on one side only, hemiplegia of that side 
occurs. When the injury is bilateral, paraplegia occurs, and when the 
nerve-roots only are involved, the paraplegia is limited to the muscles sup- 
plied by those nerves. The degree of paralysis may increase as the cord 



Fig. 237. 



Fig. 238. 




FlG. 237. — Anaesthesia resulting from a lesion of the fifth cervical segment (Starr). 

Fig. 238. — Area of anaesthesia in a lesion involving the sixth cervical segment on the right and the fifth 

cervical segment on the left. (After Starr.) 



becomes involved in secondary degenerative processes extending upward, 
or it may diminish as the pathological process in the cord improves. 

In locating a fracture by the height of the paralysis, it should be 
recollected that the nerve-roots and branches run obliquely downward 
within the vertebral canal and do not escape at the intervertebral opening 
corresponding to* their points of origin from the medulla. The diagram 
(Fig. 234) of Dejerine shows the usual relation between the various seg- 
ments of the cord, the points of exit of the nerve-roots and spines and 
bodies of the vertebrae. 



252 



TREATISE OX FRACTURES 



Sensory Paralysis. — The degree and character of sensory paralysis 
are dependent upon the presence of complete transverse lesions, of partial 
lesions, and of injury to nerve-roots. Any destruction of the sensory 
areas in the cord will be followed by the loss of sensation — anaesthesia — 
which may be divided into tactile anaesthesia, analgesia, thermo-anaes- 
thesia, and loss of muscular sense or imperfect coordination. Lesions of 
sensory roots will involve all of these sensory phenomena, whereas lesions 
of the cord itself, owing to the different courses pursued by the sensory 



Fig. 239. 



Fig. 240. 




Fig. 239. — Anaesthesia produced by a lesion of the seventh cervical segment. Hyperesthesia 

is shown by dotted area. (After Herter.) 
Fig. 240. — Anaesthesia produced by a lesion of the first dorsal segment. Hyperesthesia 

is shown by dotted area. (After Bruns.) 



nerve-fibres, make it possible for one form of sensation to be lost, while 
others are preserved. This accounts for the irregularity of distribution of 
the various forms of anaesthesia in partial lesions of the cord (Figs, 
237-256). 

In complete transverse lesions of the cord there is complete transverse 
anaesthesia of the body below the segment which is destroyed. The 
location of the lesion in the cord may be accurately determined by 
localizing the area of anaesthesia. It must be remembered that the exit 
of the nerve-roots takes place not at their points of emergence from 
the cord, but at a lower level, as shown in Figs. 243 and 244. Chipault 



FEACTUBES OF THE VERTEBRAE 



253 



gives the following rules for determining the relation of the segments 
to the spinous processes of the vertebrae : " In the cervical region add one 
to the number of the vertebrae, and this will give the segment opposite 
to it. In the upper dorsal region add two ; from the sixth to the eleventh 
dorsal vertebrae add three. The lower part of the eleventh dorsal spinous 
process and the space below it are opposite to the lower three lumbar 



Fig. 241. 



Fig. 242. 






Fig. 241. — -Areas of anaesthesia in fracture of the spine involving the sixth and 
seventh cervical vertebras. The lesion is just below the centre for the subscapular 

muscle. (After Thorburn.) 
Fig. 242. — Right-sided anaesthesia due to lesions of the fifth cervical segment, and 
left-sided araesthesia due to a lesion of the first dorsal segment. Note the distribu- 
tion of the anaesthesia on the inner surface of the left arm. (After Wichmann.) 



segments. The twelfth dorsal spinous process and the surface below it 
are opposite the sacral segments." 

The spinal cord terminates at the lower surface of the first lumbar 
vertebra. The remaining part of the spinal canal is occupied by the 
cauda equina ; hence fractures below the first lumbar vertebra cannot 
compress the cord itself but only the leash of nerve-roots and branches 
constituting the cauda. The spinal canal is much wider than the cord and 
its membranes. Considerable displacement is therefore necessary to 
actually pinch the medulla. 



254 



TEEATISE OX FBACTURES 



Cushing, in commenting upon the fact that lesions are found at a 
higher level than the area of anaesthesia, states that : " This is explained 
by the investigations of Sherrington, who found that the cutaneous 
area belonging to each spinal segment so overlaps those of the neighboring 
segments, and that the cutaneous branches of the posterior primary divi- 
sion of the spinal nerves anastomose so freely with each other, that in no 
instance does a single segment or root wholly supply a given area of skin 



Fig. 243. 



Fig. 244. 




Figs. 243 and 244. — Anaesthesia produced by a lesion of the eleventh dorsal segment. Anterior and 
posterior views. (After Wichmann. ) 



(or a single muscle as well), but at least three (and Brims says five) of 
them participate. Hence the upper border of anaesthesia points to a lesion 
of the next higher, or perhaps the second higher, segment than that repre- 
sented by the level of anaesthesia. As the zone or area supplied by the 
upper of the affected segments is also supplied by the segment, or perhaps 
the two segments above it, this is not anaesthetic, but may be the seat of 
diminished or uncertain sensations or hyperesthesia. The lowest level 
of the intraspinal lesion corresponds to the highest level of the sen- 
sory disturbance." 




' " r — ~ ■-■■■-■■■• %: 



FRACTURES- OF THE VERTEBRAE 255 

In complete lesions of the cord there may be irregular areas of anaes- 
thesia, and there may be diminished sensation or hyperesthesia. In 
addition there may be darting pains felt in the limbs when the partially 
paralyzed extremities are moved. The occurrence of such pains is, under 
some circumstances, a sign of returning innervation, and, therefore, a sign 
of improvement. In partial lesions the area of anaesthesia may be oblique, 
indicating an oblique lesion of the 

cord or a localized injury due to the » j 

pressure of fragments of bone. 

Above the area of anaesthesia 
there is generally hyperaesthesia, 
while between the two there may be 
analgesia and thermal anaesthesia. 
This is due to the distribution of 
nerve-centres and often to the pres- 
ence of a hemorrhage within the 
cord, to a subsequent inflammatory 
process that may intensify the dis- 
integration, or to the formation of 
an extensive cicatrix. In unilateral 
lesions it will usually be found that 
there are tactile anaesthesia, anal- 
gesia, thermo-analgesia on the side 
of the body opposite the lesion, to- 
gether with some hyperaesthesia of 
all of these sensations on the same 
side of the body as the lesion. 

Disturbances of Reflexes. — 
This is a symptom of very great im- 
portance in injury to the spinal cord. 
The majority of the reflexes are 

known tO have mechanisms in the Fig. 245.— Area of anaesthesia following injury 
1 j ,~™ n to the seventh dorsal segment. The area is higher 

Spinal COrCl. 1 heSe reflexes may posteriorly, as shown. (.After Wichmann.) 

be classified as : 

The Beep or Tendon Reflexes. — A loss of tendon reflex implies a 
destruction of sensory nerves, or of sensory reflex fibres in the cord, 
or of the motor mechanism. If it is possible to exclude a lesion of a 
nerve-trunk, the loss of a reflex implies a lesion of the spinal cord. 
The knee-jerk is lost in complete transverse lesions, and is diminished 
in partial lesions and in lesions of the second, third, and fourth lumbar 
segments. The complete loss of the knee-jerk is generally a positive 
indication of complete destruction of the cord, and the persistence of its 
absence is always very significant of complete destruction. The knee- 
jerk may be exaggerated in partial lesions and in recovery from the 




256 



TEEATISE OX FBACTITRES 



lesions of hsematomyelia. Ankle-clonus usually accompanies exaggera- 
tion of the patellar reflex. The plantar reflex is lost in lesions involving 
the upper three sacral segments, and in lesions above these levels it is 
reversed and altered to the Babinski reflex. This latter generally is an 
indication of a lesion of the lateral column of the cord or in the 
motor tract. 

The Superficial or Cutaneous Reflexes. — These are of such variable 
occurrence that their absence is of very little significance. The presence 



Fig. 246. 



Fig. 247. 




Figs. 246 and 247. — Areaof anaesthesia produced by a lesion of the lower two lumbar segments on 
the left side and of the entire lumbar segment of the right side. Anterior and posterior views. (After 

Starr and McBurney.) 



of these reflexes demonstrates that the reflex arc upon which it depends 
is in normal condition. The superficial reflexes of most value are the 
epigastric, abdominal, cremasteric, and plantar. 

The Reflex Mechanisms Governing the Bladder and Rectum. — The 
centres controlling the mechanism of the bladder and rectum are located 
in the fourth and fifth sacral segment of the spinal cord. Retention 
of urine is one of the most frequent symptoms of injury to the cord. 



FRACTURES OF THE VERTEBRA 



257 



It is due to paralysis of the detrusor urinae muscle. In some cases the 
distention of the bladder overcomes the constrictive action of the sphinc- 
ters and true incontinence occurs. In most cases, however, the inconti- 
nence is one of retention. In a few recorded cases rupture of the bladder 
has resulted on account of the strong constrictive action of the sphincter. 
In some cases there is a constant dribbling" of urine without distention. 
In cases in which catheterization has to be frequently performed, there 
usually results a cystitis with probably a subsequent pyelitis and nephritis. 



Fig. 248. 



Fig. 249. 




A 



I 



^%w 




Figs. 248 and 249. — Anaesthesia following a lesion of the fifth lumbar segment. (After Eulenberg. ) 



It is almost impossible to catheterize through months of life and not 
produce a cystitis, even though great care as to asepsis is given the 
withdrawal of urine. 

In lesions of the cervical and dorsal segments tympanitic distention 
of the abdomen takes place with coincident constipation. This is later 
replaced by incontinence of faxes. The incontinence of faeces takes place 
without the sensation of having a bowel movement; control is absent, 
due to paralysis of the anal sphincter; when the stools are semi-liquid 
17 



258 



TREATISE ON FRACTURES 



continuous evacuations are the rule. When the stools are formed, evacua- 
tion of the rectum may have to be accomplished by digital manipulation. 
Disturbance in the action of the bladder and rectum takes place in lesions 
at various levels and is not indicative of lesions of any particular segments. 
Priapism is a common accompaniment of injury of the cord. It 
generally appears within the first forty-eight hours after the injury, and 

may last several weeks. As a rule it 



P 







disappears within a week. It is 
seen most frequently in fractures 
of the dorsal and upper lumbar ver- 
tebrae. It seems to diminish in fre- 
quency as the injury occurs lower 
in the vertebral column, and is 
never seen in fractures below the 
second lumbar vertebra. Introduc- 
tion of the catheter to relieve a dis- 
tended bladder may produce an 
increase of the erection or cause a 
partial erection if none was pre- 
viously present; seminal emissions 
are very rare. 

Trophic and Vasomotor 
Disturbances. — Trophic changes 
take place after fractures and dislo- 
cation of the vertebra? accompanied 
by injury to the cord. The presence 
of nerve-cells and fibres devoted 
exclusively to the control of nutri- 
tive changes has not been definitely 
determined. It is known, however, 
that there are many trophic disturb- 
ances which result from injury to 
the spinal cord segments. They are 
very generally accompanied by 
vasomotor disturbances. The most common trophic changes are atrophy 
of muscles, bed-sores, and cystitis, The atrophy of muscles is too> rapid to 
be acoounted for by disuse. This atrophy is most noticeable in the flexor 
groups of muscles. Bed-sores occur most rapidly when there is con- 
tinued pressure unrelieved by changes in position of the patient. They 
occur most frequently over the sacrum, over the great trochanters, upon 
the outer surface of the knees, and upon the heels ; in other words, at the 
spots subject to continuous pressure while lying in bed. Their occurrence 
may be minimized by frequent changes in position, scrupulous cleanliness, 
bathing the skin and dusting it with such powders as zinc stearate, local 
rubbing with alcohol and alum, and by the substitution of the air- or 



PlG. 250. — Anaesthesia following a lesion of the 
first sacral segment. (.After Starr.) 



FRACTURES OF THE VERTEBRA 259 

water-bed for the ordinary mattress. Cystitis occurs rapidly after the in- 
troduction and continued use of the catheter. While it is doubtless true 
that the cystitis is due to the introduction of bacteria by the catheterization, 
the cystitis probably would net appear so soon in normal bladders. Cath- 
eterization should be entrusted only to those attendants who 1 realize the 
necessity for absolute cleanliness and conscientious asepsis. 

The vasomotor disturbances are the result of angioparalysis or an 
angiospasm. In angioparalysis the arterioles dilate, the capillaries be- 
come distended with blood, and the parts are congested ; clinically there 
is marked redness of the cutaneous or mucous surfaces. In angiospasm 
the arterioles are in a state of irritation or spasm; there is less blood to 

Fig. 251. Fig. 252. 



• 





Figs. 251 and 252. — Show area of anaesthesia in fracture involving the 
fourth lumbar segment. (After Wichmann.) 

the part, the capillaries are constricted, and the parts are pale or blue, and 
have usually a mottled appearance. The vasomotor changes are con- 
trolled by the vasomotor nerves, which are a part of the sympathetic sys- 
tem. In angioparalysis there is usually a local elevation of temperature, 
but in angiospasm the local temperature is subnormal. 

Symptoms Associated with Lesions of Various Segments. — Upper 
Four Cervical Vertebra. — Death may be sudden, from involvement 
of the vital centres in the medulla or from lesions of the centres of the 
phrenic nerves and consequent paralysis of respiration. Deformity may 
be demonstrated by palpation of the posterior wall of the pharynx. In 
those cases which do not immediately die, there is usually a rapid pulse, 
low blood-pressure, high or subnormal temperature, pain along the course 
of the occipital nerves, pain on moving the head, which is held rigid, 



260 



TEEATISE OX FRACTUKES 



and sudden death may result from the manipulations during examination 
of the parts or from a slight jarring of the bed. 

Lower Three Cervical and First Dorsal Vertebra. — Fracture 
or dislocation of these vertebrae is the result of hyperflexion of the cervical 
spine, and a lesion of the cervical enlargement of the medulla may be 
produced. The symptoms of lesions involving the upper part of the 



Fig. 253. 



."'■ 



Fig. 254. 







f 



* 




I : 



; 







Fig. 253. — Anaesthesia following a lesion of the second sacral segment. (After Oppenheim, Huber and 

Starr.) 
Fig. 254. — Anaesthesia following a lesion of the third sacral segment. (After Oppenheim, Huber and 

Starr. ) 

cervical enlargement of the cord are to be differentiated from those seen 
in lesions of the lower part of the cervical enlargement. 

Upper Part of Cervical Enlargement. — Pulse rapid, temperature high, 
blood-pressure high, paralysis of arms, which are relaxed at the patient's 
sides, anaesthesia below the deltoid area and over the shoulder- joint, pain 
in neck and shoulders, paralysis and exaggerated reflexes of lower extremi- 
ties, retention of urine, paralysis of rectum, priapism, respiration diagram- 
matic, trophic changes are rapid, unusual sweating of the entire body, and 
death within ten davs or two weeks, and often sooner. 



FBACTUBES OF THE YEBTEBE^E 



261 



Lower Part of Cervical Enlargement. — The position of the upper 
extremities is more or less characteristic. There is partial paralysis of 
the arms, which generally are abducted, the forearms flexed, the hands 
resting on the chest. The position is due to absence of paralysis of 
the shoulder muscles and flexors of the forearms. The anaesthesia is 
more marked on the inner side of the arms and forearms and is total in 



Fig. 255. 



Fig. 256. 



* 



, ■ J I 





V 



V 




n 



Fig. 255. — Anaesthesia following a lesion of the fourth sacral segment. (After Oppenheim, Huber and 

Starr. ) 
Fig. 256. — Anaesthesia due to compression of the cauda equina. (After Starr and Lloyd-) 

the hands ; it also affects the body, its upper limits being about the level 
of the nipples; above this there is hyperesthesia, which extends to the 
outer surface of the shoulders and arms. There is paralysis of the body 
and lower extremities. The reflexes of the legs may be absent at first 
and later exaggerated. Pain is present in the outer surfaces of the 
shoulders, arms, and forearms. Priapism, retention of urine, and paraly- 
sis of the rectum are also present. When the lesion affects the first dorsal 
segment, there may be oculopupillary paralysis, contraction of the pupil, 
narrowing of the palpebral fissure, and retraction of the eyeball. 



262 TEEATISE 0^ FKACTUKES 

Dorsal Vertebra. — In injury of the dorsal segments of the cord 
there will be paralysis of the abdominal and back muscles and of the lower 
extremities. Paralysis of bladder and rectum occurs, and anaesthesia 
about the trunk with an area of hyperesthesia above it. The level of the 
anaesthesia, is an indication of the site of the cord injury. Sherrington has 
shown that the level of the anaesthesia is not on a level with the lesion of 
the cord, but that it is from three to four inches below the level of the 
lesion. This is due to the overlapping or anastomosis of the sensory 
nerve filaments, and to the circumstance that the intercostal nerves of one 
segment supply the skin directly related to two or at times three adjacent 
segments of the cord. In addition the sensory fibres entering the cord 
ascend to two higher segments before terminating. Starr reports a case 
in which there was a lesion of the eighth dorsal segment in a fracture of 
the sixth dorsal vertebra, and the line of anaesthesia corresponded to the 
distribution of the tenth dorsal nerve, being three inches below the level 
of the injury. The area of hyperesthesia above that of anaesthesia is 
due to the fact that centres above the segment injured are in a state 
of irritation. 

In those cases in which there is not complete destruction of the cord, 
the patients often refer to this area of hyperesthesia all sensations com- 
ing up from the legs. Starr considers that this symptom is of value in 
differentiating complete from partial lesions of the cord. 

A combination of symptoms is occasionally present in lesions of one- 
half of the cord in the dorsal region to which has often been given the 
name of Brown-Sequard paralysis. These symptoms may, however, be 
present in unilateral lesions at other levels. The symptoms are: (a) on 
the side of the lesion : paralysis with rigidity, increased tendon reflexes, 
temporary elevation of temperature, diminished muscular sense in the 
leg, hyperesthesia to touch, temperature and pain up to the level of the 
lesion, a narrow zone of anaesthesia about the body to touch, temperature 
and pain ; (b) on the side opposite to the lesion : absence of paralysis, slight 
increase of reflexes, anaesthesia to touch, temperature, and pain up to a line 
passing about the body about an inch lower than the zone of anaesthesia 
on the side of the lesion. 

Lower Two Dorsal and Upper Lumbar Vertebrae. — Injuries to 
these vertebrae, as a rule, involve the lumbar enlargement of the cord. 
The lesion may involve the upper or lower part of the lumbar enlarge- 
ment, or it may be limited to the conus terminalis or the lower three 
sacral segments. 

Complete Transverse Lesion of the Upper Part of the Lumbar En- 
largement. — Total paralysis of abdominal and thigh muscles, with flac- 
cidity and atrophy, reaction of degeneration and a loss of superficial and 
deep reflexes, paralysis without atrophy or reaction of degeneration in 
muscles of legs and feet, the legs lie extended and flaccid, loss of bladder 
and rectal control, girdle sensations and anaesthesia as high as Poupart's 



FBACTUBES OF THE VERTEBRAE 263 

ligament, and failure of contraction of abdominal muscles on compression 
of testicle (Kocher's reflex). When the lesion does not involve the upper 
two lumbar segments there may be an area of hyperesthesia on the front 
of the thigh and anaesthesia may be confined to the area corresponding 
to the lumbar segment below these two. Recovery, if it occurs, is attended 
with permanent paralysis of the thighs. 

Complete Transverse Lesion of the Lower Part of the Lumbar 
Enlargement. — Paralysis is limited to the legs below the knees, and at 
times only the peronei group of muscles and feet are involved, atrophy of 
these muscles and reaction of degeneration, loss of bladder and rectal 
control due to relaxation of both sphincters; anaesthesia is generally 
limited to the posterior and outer aspect of the thigh, and outer part of 
the leg and foot, and, as Starr has noted, it may be limited to peculiar 
areas; the thighs and legs are flexed, the knee-jerks may or may not be 
present ; ankle-clonus and toe-reflex are absent, and testicular sensation is 
preserved. Recovery in these cases makes locomotion possible, by appli- 
cation of suitable apparatus to hold the knees and ankles stiff and the 
use of crutches, because the thigh muscles are not paralyzed. 

Lesions of the Conns Terminalis. — Loss of bladder and rectal con- 
trol, loss of sexual power, and anaesthesia limited to the region of the 
anus and posterior part of the scrotum in the male and posterior half 
of the labia and perineum in the female; or the area of anaesthesia may 
be heart-shaped over the region of the sacrum. 

Lower Four Lumbar Vertebrae of the Sacrum. — Fracture of 
these vertebrae may produce compression of the cauda equina. The symp- 
toms of these lesions may be similar to those of injuries of the spinal cord 
itself, because the cauda equina is composed of nerve-roots coming from 
the lumbar enlargement. Fractures in this region do not always give 
the same symptoms of a complete transverse lesion of the lumbar enlarge- 
ment, since many of the nerve-roots may escape injury. These nerve- 
roots have the power of regeneration. The symptoms are loss of bladder 
and rectal control, anaesthesia in a heart-shaped area over the sacral 
region, buttocks, or posterior portion of the genital regions. The symp- 
toms may show unequal distribution. Complete recovery is possible, by 
operation, after these injuries. Fractures may produce intense pain, 
radiating along the course of the nerves injured when the lesion is partial 
and the nerves are lacerated; the location of the pain may be on a higher 
level than the anaesthesia and is often a guide to the seat of fracture. 
These pains are generally referred to the peripheral termination of the 
compressed or lacerated nerves. 

While the symptoms detailed above are those seen in complete trans- 
verse lesions at various levels, it is probable that in partial lesions the 
symptoms will be asymmetrical. The areas of anaesthesia and the extent 
of paralysis may vary on the two sides of the body, and the degree of 
paralysis and the height of anaesthesia may increase on account of an 



26± TREATISE OX FRACTURES 

increasing area of degeneration or the spreading of a hemorrhage around 
or into the cord. 

Hemorrhage in the Dura and Spinal Cord. — The blood may be 
extradural; it may be subdural (haematorrachis), or it may be in the 
substance of the spinal cord (haematomyelia). The symptoms of sub- 
dural hemorrhage are not always definite. They generally consist of pain, 
sharp and paroxysmal in character, along the spine and at times referred 
to the course of the nerve-trunks. These pains may be accompanied by 
muscular spasm, opisthotonos, convulsions, and paraplegia, or by an 
irregular distribution of the paralysis. The paralysis rarely is sudden 
in onset, in most cases becomes complete after from four to< six days, 
and persists for a period of several weeks to two months, when it 
gradually disappears. The suddenness of the onset of the symptoms is 
dependent upon the size of the vessel injured. Lumbar puncture will dis- 
close hemorrhage into the spinal fluid. The source of the hemorrhage 
is usually from the venous plexus about the cord, and the amount of the 
hemorrhage is dependent upon the size of the vessel injured and its loca- 
tion. Injury to a vessel high up in the spinal canal probably will be 
accompanied by considerable hemorrhage, and which will be greater in 
amount than from vessels injured at a lower level. 

The Symptoms of Hemorrhage Into the Spinal Cord Itself. — The 
usual site is in the region of the fourth, fifth, and sixth cervical vertebrae 
and is considered by Thorburn to be due to hyperflexion of the spine in 
this region. When the hemorrhage takes place in the white substance 
of the cord there occurs paraplegia below the segment involved. When a 
hemorrhage takes place in the gray substance of the cord there is partial 
wasting of muscles and anaesthesia of the upper extremities with loss of 
some reflexes. The onset of the symptoms is sudden, the prognosis often 
fatal, and in the cases in which recovery takes place there is always mus- 
cular weakness due to the destruction of the motor neurons. 

Diagnosis. — It is not always easy to make a positive diagnosis of 
fracture of the vertebrae. In isolated fracture of the spinous or transverse 
processes without symptoms pointing to compression of the spinal cord, 
the diagnosis may be uncertain. Generally, however, there will be local 
pain and tenderness on pressure, some irregularity of the spines of the 
vertebrae affected, swelling of the soft parts, late ecchymosis and possibly 
the late appearance of symptoms of compression of the cord from pressure 
by a haematoma or exuberant callus. Crepitus and deformity, if they 
exist, are important points in diagnosis. 

In fractures of the vertebrae accompanied by lesions of the spinal cord, 
it is often impossible to determine the extent of the fracture from the 
cord symptoms. The symptoms of injury to the cord may be slight in 
severe fractures, and vice versa. It may also be impossible to determine 
the extent of the cord injury at once; several days must elapse in some 
cases for the surgeon to be able to fully estimate the degree of injury 



FKACTTJKES OF THE VERTEBRA 265 

and to determine whether the lesion is complete or partial. The patient 
should be radiographed as soon as possible, and the extent of fracture and 
the degree of displacement of fragments determined. In fracture asso- 
ciated with injury to the spinal cord the important facts to be determined 
are the level of the cord lesion and the extent of compression or destruc- 
tion of the cord that has occurred. The level of the lesion of the cord may 
be determined by comparing the muscles paralyzed and the levels of 
anaesthesia with the tables (Fig. 234). These show the relation of the 
segments of the injured cord, and of the roots and exits of the spinal 
nerves to the spinal vertebrae, the location for sensibility and motion, the 
segmental localization of the automatic centres, and the superficial and 
deep reflexes of the spinal cord. 

The determination of the degree of the lesion of the spinal cord is 
not always possible. When there is any sensation in the parts below 
the lesion, such as pain, tingling, numbness, and when change in, position 
of the extremities or distention of the bladder is noticeable, the probabili- 
ties are that the lesion is not complete. When anaesthesia is apparently 
complete below the lesion, it is sometimes possible to cause sensation 
by deep picking with a needle ; in these cases the sensation may be referred 
to the area of hyperesthesia above that of anaesthesia, This is not pos- 
sible if the lesion is complete. If the lesion is total the patella reflex is 
permanently lost, the paralysis of the legs is flaccid, no rigidity is present 
on passive motion, and the line of anaesthesia is sharply defined. In partial 
lesions the tendon reflexes may be primarily lost, but they later return 
and may become exaggerated. In complete lesions the superficial and 
deep reflexes are lost, there are greater trophic and vasomotor changes, 
priapism is present, and there is complete loss of bladder and rectal control. 

Prognosis. — In fracture of the vertebrae unaccompanied by injury to 
the spinal cord, the prognosis should be favorable not only for life, but 
also for ultimate restoration of health. The rarity of such condition 
without injury to the spinal cord is well known. In isolated fractures 
of the spinous or transverse processes, and in compression fractures of 
the body of the vertebrae of moderate degree without cord injury, the 
prognosis will depend upon the subsequent development of excessive 
callus, which may produce pressure, or upon the amount of angulation 
produced by the compression of the body of the vertebrae. 

The prognosis of fractures of the vertebrae accompanied by injury 
to the spinal cord is not very favorable. It will depend in great measure 
upon the severity of the symptoms presented and the degree of the spinal 
cord lesion. Many patients die from myelitis, exhaustion of bed-sores, 
and cystitis. Patients do at times recover, but usually with considerable 
disability from loss of power in the legs and imperfect control of the 
bladder and rectum. The lower the seat of fracture the better the chance 
of recovery, both as to life and function. In cases which finally prove 
fatal, life is the more prolonged as the site of fracture descends the spinal 



266 TEEATISE OX FKACTUKES 

column. Repair of the spinal cord does not occur, and there is never any 
restoration of continuity of its nerve-fibres. There is perhaps evidence 
that this statement should be modified. The seat of the lesion is replaced 
by scar tissue. Lesions involving the spinal nerve-roots are capable of 
complete recovery and regeneration of nerve-tissue. These statements 
should be carefully considered when the radiograph shows the presence of 
bony pressure combined with symptoms of complete destruction of the 
cord. In partial lesions where the spinal cord is only slightly involved, 
or where only one or two motor or sensory tracts are involved, partial 
restoration of function may follow the operative relief of pressure. In 
cases in which the spinal lesion is an extra- or subdural hemorrhage or a 
bleeding into the cord itself, restoration of function will generally occur 
to a greater or less degree. Occasionally it may be complete. On this 
account great care should be taken to save the patient's strength, and 
particular attention should be given to the bladder and rectum and to the 
prevention of pressure sores. 

Treatment. — All cases of suspected fracture of the vertebrae should 
be handled very carefully to prevent the production or the increasing of 
displacement of fragments and consequent injury of the spinal cord. 
The patient should be transported, examined, and moved about in bed 
Avith the greatest caution. Movements made to determine the presence 
of crepitus should be avoided. 

Treatment will depend in a great measure upon the site of fracture, 
the portion of the vertebrae fractured, and the presence or absence of 
injury to the spinal cord. In fractures of the spinous process, laminae, 
or arches without symptoms of pressure on the spinal cord or displace- 
ment of the fragments, the treatment should consist in immobilization of 
the parts with a well-fitting plaster-of -Paris case. In compression frac- 
tures of the bodies of the vertebrae, in dislocation fractures without symp- 
toms of injury to the cord, and in those cases in which there is deformity 
present at the seat of fracture, reduction of the fragments should be 
attempted by traction, combined with hyperextension and, after reduction, 
by the application of a plaster-of-Paris case. Hyperflexion is best ob- 
tained by horizontal suspension of the prone patient upon a suitable 
strip of stout muslin, and when the proper degree of hyperextension has 
been attained the plaster case should be applied. 

When a complete transverse lesion of the cord is present, the ex- 
pectant form of treatment must as a rule be followed. When there are 
symptoms of injury to the spinal cord, whether the patient is subjected 
to operative intervention or not, he should be placed upon an air- or 
water-bed. Every effort should be made to prevent the occurrence of 
pressure sores, and great care should be taken to keep the sheets dry, clean, 
free of wrinkles and bread crumbs. As soon as the sheet becomes moist, 
either from urine or faeces, it should be changed. The back, thighs, legs, 
and feet should be rubbed twice a day with alcohol and alum, and, if neces- 



FRACTURES OF THE VERTEBRAE 267 

sary, additional air rings may be placed under the sacrum and heels. 
When a pressure sore has developed, it should be kept dry and clean by 
the use of alcohol or other antiseptic applications, dusting' powders, and 
dry dressings. All moist sloughs should be cut away as they develop. If 
kept dry and aseptic they may be allowed to remain, since healing may 
then take place under the sterile scab or slough. The development of a 
cystitis usually follows the catheterization necessitated in retention due 
to paralysis. The possibility of retention of urine should always be 
recollected at the first examination of a patient suspected of vertebral 
injury. Palpation and catheterization will frequently show that this 
condition has been overlooked. The distended bladder gives the injured 
patient, usually perfectly conscious, no inconvenience or pain. Inex- 
perienced attendants may even say he has passed urine, when really the 
outflow has been merely the dribbling due to complete distention of a 
tightly filled bladder. The use of a catheter will reveal this unsuspected 
retention of urine due to paralysis of the bladder. This is favored 
by the vasomotor and trophic changes which take place in the bladder walls 
as an accompaniment of the paralysis. If possible, catheterization should 
not be performed, but the urine should be allowed to overflow into a suit- 
able urinal. In those cases which require catheterization, the bladder 
should be irrigated twice daily with boric acid solution (2 to 5 per cent.), 
and a small quantity of this solution should be left in the bladder. When 
cystitis develops, more frequent irrigations may be used. In all cases the 
patient should be given internally hexamethylenamin, 7 grains, three times 
daily. Suprapubic cystostomy for drainage is not recommended. Great 
care should be taken to keep the patient dry and clean after each move- 
ment of the bowels. As a rule the bowel movements are semi-liquid and 
frequent. It may be necessary to cleanse the rectum by means of enemata 
or at times to empty it, because of impaction, by means of a spoon. Tympa- 
nites may be lessened by the use of ice-bags, hot-water bottles, stupes; 
and by eserin, given hypodermically. 

Operative Treatment. — Indications for and against laminectomy for 
restoration of bony contour or relief of medullary symptoms may be 
formulated : 

1. Operation is contra-indicated in the presence of shock, or when high 
or subnormal temperature, and rapid pulse or respiration are present. 

2. When there is evidence of complete transverse destruction of 
the cord. 

3. Operation is indicated when the symptoms show partial destruction 
of the cord or compression from a blood clot or fragment of bone. 

4. It may be advisable to perform a delayed operation in apparently 
complete transverse lesions because the symptoms sometimes change and 
become less severe, showing that the primary symptoms were due to con- 
cussion or to extradural hemorrhage. 

5. If after two weeks improvement is present, operation is indicated. 



268 TKEATISE OX FBACTUKES 

6. When the radiograph shows pressure from displaced fragments 
and the symptoms point to a partial lesion of the cord, immediate opera- 
tion is indicated; when, however, the symptoms are those of complete 
destruction of the cord and the radiograph shows marked displacement of 
fragments, operation is useless. 

7. Operation is indicated in all lesions of the cauda equina or posterior 
nerve-roots. In these cases restoration of function should follow the 
operative restoration of continuity by suture of the nerves. 

8. Operation is indicated when the symptoms point to extra- or 
subdural hemorrhage. In these instances the symptoms have a gradual 
onset, the paralysis is incomplete, and the areas of anaesthesia are irregular. 

9. It may be argued that there are reported cases of complete section 
of the cord (Harte, Munro) in which restoration of function has taken 
place after operation. It is with this in mind that one is often prompted 
to operate on apparently hopeless cases. It may be said, however, that 
the operative mortality should be considered, that many cases show as 
much improvement without operation as with operation; and that it is 
only in those cases of possible destruction of the cord, which show 
improvement after several weeks, that operation is indicated. 

10. With definite evidence of fracture or dislocation and complete 
bilateral circular paralysis of motion and sensation, operation is 
contra-indicated. 

11. When the symptoms are those of compression by blood (extra- 
dural or subdural) without fracture or dislocation, do not operate. 
Perform lumbar puncture. 

12. When the symptoms are those of compression by blood and frag- 
ments of bone, and the paralysis of motion and sensation is not com- 
plete, immediate operation is indicated; and, especially, if the symptoms 
are persistent. 

13. Do not operate in the presence of severe shock. 

14. Late operation is indicated in those cases in which symptoms of 
pressure are progressive, or in which the pressure is evidently due to the 
growth of callus about the seat of fracture. 

15. Late operation should be performed when improvement has taken 
place in patients in whom symptoms of improvement are not progressive. 
When symptoms are retrogressive, operation is not indicated. 

The details of laminectomy vary with different operators. As a gen- 
eral rule a median incision over the spinous processes at the site of fracture 
or kyphosis is the best. The muscles are separated from the vertebral 
column and retracted, and the laminae exposed. The spinous processes 
are usually cut away and the spinal canal exposed by sawing through 
the laminae on each side or dividing them with a rachitome. Displaced 
fragments are reduced so as to relieve pressure on the cord. They may 
be held in place by wiring. Want of success in relieving spinal symptoms 



FBACTUBES OF THE VERTEBRA 



269 



i^ 




2T0 



TKEATISE OX FBACTURES 



is to a great extent clue to the circumstance that the injurious pressure 
may have been exerted by movement of the vertebral bodies at the time of 
injury. It is difficult to restore displaced bodies when they have been 
fragmented because of their situation in front of the spinal marrow. 
Care should be taken not to press forward any of the fragments into the 
cord in removing fragments. These should be removed rather than 
merely elevated. Dislocation of the arches or fracture-dislocations are 



Fig. 260. 



Fig. 261. 




Figs. 260 and 261. — Photographs showing use of convalescent brace in the treatment of 
fractures of cervical vertebrae. 

best reduced after the removal of several laminae, so that one may see 
that no additional pressure is produced at the point of compression. The 
dura will usually be found to be not torn. It should always be opened. 
Any subdural clot should be removed. After reducing any displacement 
and removing fragments or blood clot, the dura should be closed without 
drainage with absorbable sutures and the wound of the soft pails sutured. 
It is useless to suture the cord when it has been completely crushed trans- 
versely. Lacerated or severed nerve-roots should be repaired by fine 
silk sutures. 



FRACTUEES OF THE VEETEBB^E 271 

After-treatment. — In all cases, whether apparently hopeless or not, 
the paralysis should be treated by massage and electricity if of the flaccid 
type ; when it is of the spastic type electricity will excite the muscles to 
spasmodic contracture and should not be used. Spasmodic contractures 
seen in partial lesions may be very annoying to the patient. They may be 
partially controlled by the use of the bromides or chloral. When the 
patient complains of severe pain, especially at the level of the injury, 
the use of morphine will often be necessary. The general health of the 
patient should be promoted by fresh air, nourishing food, and pleas- 
ant companions. 

During the stage of convalescence in those cases unassociated with 
paralysis support to the spine should be given by means of braces 
(Figs. 257-261). 



CHAPTER XIII 



Interclavicular notch 
Facet for clavicle 



Manubrium 



FRACTURES OF THE STERNUM, THE RIBS, AND THE 
COSTAL CARTILAGES 

Fractures of the Sternum 

Anatomy. — The sternum (Fig. 262) or breast-bone is situated in 
the middle of the anterior portion of the thorax; it joins the costal 
cartilage of the first seven ribs on each side; and articulates with the inner 
extremities of the clavicles, forming the shoulder girdle anteriorly. It 
is formed of three parts : the manubrium, the gladiolus or body, and the 
xiphoid or ensiform process or appendix. 

The manubrium has on its upper 
margin three notches : the median or 
interclavicular notch, and two lat- 
eral or clavicular notches for articu- 
lation with the sternal extremities 
of the clavicles. Below these are ad- 
ditional notches to accommodate 
the costal ends of the first ribs. The 
manubrium, is triangular in shape, 
with its base above. The gladiolus is 
flattened, narrow above, and has on 
each side a demi facet at its upper 
angle, which unites with another 
demi facet on the lower corner of the 
manubrium for the articulation of 
the cartilage of the second rib. Be- 
low this demi facet are additional 
notches for the cartilages of the 
third, fourth, and fifth costal carti- 
lages. The sixth and seventh costal 
cartilages articulate with the con- 
stricted lower end of the gladiolus by 
separate notches, the notch for the 
seventh being formed by a demi facet on the xiphoid cartilage. 

The xiphoid cartilage sometimes remains cartilaginous until advanced 
life before it ossifies and becomes ankylosed with the gladiolus. It may 
be perforated, notched, or irregular in outline. 

Surface Markings. — The anterior surface of the sternum may be 
palpated throughout. The junction of the manubrium and gladiolus is 
marked by a transverse ridge at the level of the second costal cartilage 
272 



Body 




Xiphoid proces 



Fig. 262. — Sternum, anterior view. 



STERNUM, RIBS, AND COSTAL CARTILAGES 



273 



(Ludwig's angle). The lower portion of the sternum, the xiphoid carti- 
lage, is generally depressed and is sometimes called the scrobiculus cordis 
or the " pit of the stomach." The sternoclavicular articulations are 
readily palpable. 

Statistics. — Bruns observed in 8560 cases, 17 instances (0.1 per cent.) 
of fracture of the sternum; Chudowsky in 2366 cases, 6 instances (0.25 
per cent.) ; and Plagemann in 1393 cases, 5 instances (0.359 P er cent.). 

Etiology.-— Fractures are rare, probably because the sternum is pro- 



Fig. 263a. 



Fig. 2636. 





Fig. 263a. — Transverse fracture of sternum; union. The gladiolus was 
fractured transversely near its junction with the manubrium. Union has 
occurred with secondary changes in the bone. The costal cartilages of the 
second and third ribs of both sides are ossified. The ensiform appendix is 

missing. (Mutter Museum, No. 1202.10.) 
Fig. 2636.— Oblique fracture of sternum; union. The gladiolus was frac- 
tured near its junction with the manubrium. The callus marking the line 
of fracture runs from the attachment of the third right costal cartilage 
obliquely downward almost to the fourth left costal cartilage and then 
curves upward to the third. The callus is smooth and prominent. (Mutter 
Museum, No. 1202.) 



tected from indirect violence by being connected with the elastic costal 
cartilages and ribs. When fracture occurs, it is usually due to such great 
violence that injury to the ribs or thoracic viscera also occurs. Fracture 
of the sternum may also be produced by violence which forcibly flexes or 
extends the spine. Thus fracture of the sternum or of the spine or of 
both together is produced. Great muscular efforts, such as occur in lifting 
heavy weights, vomiting or in parturition, have been followed by this 
fracture. It may also be caused by direct violence, such as a blow of 
moderate force, limited to a small area, and by bullets. 

Varieties. — The first portion of the sternum and the last portion very 
18 



274 



TREATISE OX FEAC1TEES 



frequently become united to the middle portion in early adult life by 
osseous union. Before this takes place there is fairly free movement 
possible at these points. In young patients it is therefore difficult to tell 
whether a given deformity is a dislocation or a fracture. Fracture may 
occur close to or at the joints. The most common site of fracture is near 
the junction of the manubrium and upper end of the gladiolus (Fig. 263). 
As a rule the line of fracture is more or less transverse. Longitudinal 
fracture should not be confounded with congenital fissure. Both are rare. 
The frequent irregularities of the ensiform cartilage should always 
be remembered. 

Symptoms. — The symptoms of fracture of the sternum are localized 
pain and tenderness, mobility, crepitus and in 
some cases deformity (Fig. 266). These 
symptoms may be exaggerated by forcible 
respiration and by change of position. The 
attitude is often characteristic. The patient as- 
sumes a sitting position, with stooping of the 
shoulders, and a part of the weight of the 



Or 




Foramen 





Fig. 264. — Sternum, showing fora- 
men due to imperfect union of 
lateral parts. 



Fig. 265. — Ossification of the sternum. A, at sixth fcetal 
month; a, centre for manubrium. B, at birth; a, for manubrium; 
b c d. for segments of body. C, at about ten years; a, manu- 
brium; b, c, d, segments of body; e, ensiform cartilage. 



shoulders is supported by the arms on each side of the bed. Late ecchy- 
moses may be observed. As a rule the anterior periosteum or the ligament 
is torn, while the periosteum on the posterior surface is stripped up and 
remains intact. Other symptoms that may be present are dyspnoea, 
expectoration of blood, and orthopncea. 

Complications. — The importance of the injury is due rather to the 
complications that may exist than to the fracture itself. There may be 
profuse hemorrhage into the mediastinum, rupture of the lungs or peri- 
cardium, and the development of an area of suppuration about the seat 
of fracture or in the mediastinum. 

Diagnosis. — This may readily be made from the objective symptoms. 



STERNUM, RIBS, AND COSTAL CARTILAGES 



275 



At times these may consist only in local tenderness, swelling, and ecchy- 
mosis, while in the other cases all of the symptoms above mentioned may 
be present. In young persons dislocation may occur between the seg- 
ments and be mistaken for a fracture. Indeed the joint between the manu- 
brium and gladiolus which is placed at the mid-point of the attachment of 
the second rib usually does not ossify until old age. Luxation is not likely 
after the age of twenty-five years. Anomalies in development cause 
longitudinal fissures or foramina in the sec- 
ond piece. These must be recollected when 
interpreting rontgenograms. 

Osseous union takes place in from six to 
eight weeks. 

Prognosis. — The prognosis is dependent 
upon the presence of complications. In 
simple uncomplicated cases there should be 
no mortality, and union should progress 
without difficulty after proper reduction of 
the fragments. Gurlt records 98 cases; of 
these 54 were simple cases with 46 recoveries 
and 8 deaths, and 44 were complicated cases 
with 1 recovery and 43 deaths. Doubtless 
in the eight cases that died there was some 
complication present. 

Treatment. — Reduction of the frag- 
ments, if deformity is present, is to be ac- 
complished by traction, hyperflexion, and 
direct pressure. A firm support such as a 
sand pillow, should be placed between the 
shoulders. The arms should then be drawn 
upward over the head and rotated outward 
slowly and with considerable force. At the 
same time pressure over the lower end of the 
anterior fragment will generally result in 
reduction. This may also' be accomplished 

by bringing the patient's head and shoulders Fig. 266.— showing type of displace- 
ment usual in fractures of the sternum. 

over the end of a table and then drawing the 

arms upward and forcibly outward. Recurrence of this deformity often 
takes place after reduction. The chest should be immobilized in an ad- 
hesive plaster swathe, or a firm cotton roller bandage. If reduction can- 
not be accomplished by these manipulative efforts, an incision should be 
made at the seat of fracture, and the depressed fragment raised by a 
suitable instrument. Retention may be made by a plate or nail or by direct 
suture with chromic catgut or silver wire. Union is firm in six to eight 
weeks; but in severe cases support should be given for a few months by 
means of a brace or gypsum jacket similar to what is worn in vertebral 




2:6 



TREATISE OX FRACTURES 



caries of upper dorsal region or after fracture of the spine. The after- 
treatment in these cases and in those in which there is no deformity con- 
sists in the use of bromides or anodynes for a few days and locally 
an ice-bag - . 

In the treatment of complications one should be guarded by general 
principles. When a localized area of suppuration occurs it should be 
promptly incised, and if its seat is the mediastinum, proper drainage along- 
side or through the sternum should be obtained. Hemorrhage from the 
internal mammary vessels as a complication of fracture may require tre- 
phining the sternum or resection of costal cartilages. 




Clavicular articulation 

Manubrium 

Angulus sterni or 
angle of Ludwig 



Body or gladiolus 



Xiphisternal articulation 
Xiphoid or ensiform 



J cartilage 



Fig. 267. — The bony thorax. 



Fractures of the Ribs and the Costal Cartilages 

Anatomy. — The ribs, consisting usually of twelve pairs, extend from 
the thoracic vertebrae outward, forward, and finally inward, terminating 
in costal cartilages in front. They form the thoracic wall. They are 
divided into the upper seven, called true or sternal ribs, the lower five, 
termed false or vertebral ribs. The lower two of the latter are known 
as the floating ribs. Occasionally rudimentary floating ribs are devel- 
oped on one or both sides of the neck having attachment to the lower cer- 
vical vertebrae. Such cervical ribs have an importance in. radiological 
study of injuries of the neck. The typical rib may be divided into the 
head, the neck, the body. The head is the posterior enlarged end, next 
to this is the constricted neck between the head and the tubercle ; the latter 
marks the beginning of the body. Beyond the tubercle the body presents 



STEENTJM, BIBS, AND COSTAL CARTILAGES 277 

a rough surface, the angle of the rib. The body is curved on two axes, 
the dorsal curve extending from the head to the angle, and beyond this 
the curve is forward and more gradual, ending in the sternal extremity 
which receives the costal cartilage. The ribs differ from one another 
somewhat, the first and second presenting marked peculiarities. They 
increase in length from the first to the seventh and then decrease to the 
twelfth. The first rib is broad and flat and is placed horizontally at the 
top of the thoracic cage. Its edges look backward and forward instead of 
upward and downward as the other ribs. The eleventh and twelfth ribs 
are short, slightly curved, the crests of the heads are wanting, and the 
tubercles have no articular surface. The ribs are developed by three 
centres of ossification ; one for the shaft, one for the head, and one for 
the tubercle. The two floating ribs, having no tubercle, have only two 
ossific centres. It is important for surgeons to bear in mind that the 
bony centres for the heads and tubercles do not appear until the sixteenth 
or twentieth year and do not unite with shaft until about five years later. 
The costal cartilages serve to connect the ribs with the sternum. The 
upper seven ribs have a direct //£*§ 

connection with the sternum 
through separate costal carti- 
lages, while the eighth, ninth 
and tenth have a common 
cartilage which joins the 
sternum in connection with 
the cartilage of the seventh 
rib. The costal cartilages are 
continuous with the ribs, in- 
crease in size from the first tO Fig. 268.— A cervical rib attached to the right side of the 
, 1111 seventh cervical vertebra. 

the seventh and then decrease 

in size and length so that the eleventh and twelfth ribs have very little 

cartilaginous end. 

The articulations of the ribs with the vertebrae are divided into costo- 
central and costotransverse articulations. In the costocentral articulation 
there are the capsular ligament, the anterior costocentral or stellate liga- 
ment, and the interarticular ligament. In the costotransverse articulation 
there are the capsular ligament, the middle costotransverse or interosseous 
ligament, the posterior costotransverse ligament, and the superior costo- 
transverse ligament. 

The costochondral articulations are formed by the junction of the 
costal cartilages with the cup-shaped ends of the ribs. 

In the chondrosternal articulation there are the interarticular liga- 
ments, the anterior superior and inferior chondrosternal ligaments, the 
capsular ligaments, and the chondroxiphoid ligament. 

Surface Markings, — The ribs can be palpated anteriorly, laterally, and 
posteriorly as far as the edge of the erector spinal muscle. Occasionally 





2T8 TEEATISE OX FRACTURES 

the twelfth rib does not extend forward as far as the edge of this muscle, 
so that in counting the ribs one should begin above. The costochondral 
junction can be palpated, and especially so in persons showing a rhachitic 
tendency. Elevating the arms and taking deep inspirations exhibit the 
ribs well. 

Statistics. — Bruns observed in 8560 cases of fracture, 819 (9.5 per 
cent.) instances of fracture of the ribs; Chudowsky in 2366 cases, 193 
(8.15 per cent.) instances; and Plagemann in 1393 cases, 40 (2.8 per 
cent.) instances of fracture of ribs. 

Pathology. — Fractures of the ribs are most frequently seen in adults 
and very rarely in children. This is accounted for by the great elasticity 




Fig. 269. — Left rib; fracture; union. The fracture occurred 10 cm. from the sternal extremity. 
Left rib; fracture; union. The fracture occurred 9 cm. from the sternal extremity. Left rib; 
fracture; union. The fracture occurred 7 cm. from the sternal extremity. (.Mutter Museum, 

Nos. 1217.37-36-34.) 

of the ribs in childhood. Green-stick fracture of the ribs doubtless occurs 
more frequently than statistics would lead one to suppose, and are often 
overlooked. In adults fractures frequently occur with little if any tearing 
of the periosteum and the symptoms are obscure. Fractures of the first 
and second ribs are unusual on account of their protected position behind 
the clavicle, and of the last two ribs on account of their mobility. Over- 
riding of fragments is impossible unless several adjoining ribs are broken. 
Angular deformity of one broken rib is also limited on account of its 
relative position to the other ribs which act as splints. 

Etiology. — Fracture of the ribs may be caused by external violence or 
by muscular action. The most usual form of external violence is a blow, 
kick, fall against a projecting surface, or with the patient's own arm be- 
neath the chest, or some compressing force. Direct violence by driving 
the rib inward causes fracture at the point of impact, and generally with 



STEBXUM, EIBS, AND COSTAL CABTILAGES 



279 



inward displacement of the ends of the fragments; hence puncture of the 
viscera is more frequently seen in this form of violence. Indirect violence, 
by depressing the chest, has a tendency to bend the rib and cause a fracture 
beginning on the external surface. Fractures by indirect violence are 
most frequent near the angle, as this is the point of greatest convexity and 
of weakness. Fracture by muscular action may be produced by violent 




Fig. 270. — Rontgenogram of healed fractures of the fourth to ninth left ribs. 

coughing and sneezing, or by lifting a heavy object. The tenth and 
eleventh ribs are most frequently the site of fracture. Pathological frac- 
tures of ribs are sometimes seen in general paralysis of the insane, 
and are probably due to trophic changes in the bone which make them 
more friable. 

Varieties of Fracture. — Fracture of the ribs (Figs. 269 and 270) are 
most frequently seen involving the lateral and anterior portions, probably 
fracture close to the angle being the most frequent. The ribs are protected 



280 TREATISE OX FRACTURES 

in the posterior region by overlying thick muscles and the shoulder blades. 
The lesion may involve only one rib, but, as a general rule, two or more 
are broken; and in some forms of injury, such as a " squeeze," ribs may 
be fractured on both sides of the body. In fracture of a single rib the 
periosteum is generally not torn; while if several ribs are fractured the 
periosteum is torn and more or less deformity may be present. Fractures 
of the rib may be open, but are rarely made so by puncture of the skin by a 
fragment of the rib. The wound is generally due to the fracturing force. 
Gunshot fractures are frequently open and may become infected. 

Symptoms. — The symptoms of an uncomplicated fracture of the ribs 
are often obscure. When only one rib is fractured the symptoms may be 
limited to local tenderness and pain on pressure, pain on deep inspiration, 





Fig. 271. — Showing relation of intercostal artery, vein, and nerve to the rib. 

a little swelling, late ecchymoses, and the presence of a nodule due to 
callus. The most common symptoms are local pain and tenderness on 
pressure, crepitus, mobility of the fragments, pain on moderate or deep 
inspiration and on anteroposterior compression of the chest. The respira- 
tion is generally "catchy " or shallow and is due to irritation of the inter- 
costal nerve by oedema, ecchymosis, callus, or fragments of bone (Fig. 
271 ). Ecchymosis appears after a few days in most cases. Swelling may 
be present at the site of fracture and is due to bruising of the soft parts by 
the initial violence. Haemoptysis or subcutaneous emphysema, or both, may 
occur when fracture is complicated with a wound of the lung. A crackling 
felt on light palpation of the skin is due to escape of air, from a puncture 
of the lung, into the pleural sac, and thence by respiration into the thoracic 
wall. This subcutaneous air may be driven long distances from the site 
of fracture and reach the face and upper part of neck, causing marked 
deformity, and creating anxiety. It is usually rapidly absorbed. Some- 



STERXUM, RIBS, AND COSTAL CARTILAGES 



281 



times such subcutaneous emphysema is about the only symptom of 
fracture of the rib. It establishes, however, the fact that a pointed frag- 
ment of bone has pierced the costal and pulmonary layers of pleura and 
opened the lung air passages. It needs no special treatment. 

Crepitus may be obtained by applying the finger-tips over the rib at 
each side of the suspected point of fracture and by causing alternate pres- 
sure (Fig. 2 /2a) ; or it may be detected by laying the palm of the hand 
over the point of tenderness while the patient coughs or the examiner 
makes firm pressure in the region of the injury with the other hand. 
Crepitus may also be detected by auscultation. Abnormal mobility may 



Fig. 2726. 




I 

Fig. 272a. — Method of making alternate pressure over rib near seat of fracture to determine abnormal 

mobility and pain. 
Fig. 272b. — Method of making anteroposterior compression of the chest-wall. In fracture pain will be 

determined by this manipulation. 



be difficult to recognize on account of the normal mobility of the chest 
wall. A valuable symptom is pain caused by anteroposterior compression 
of the chest wall (Fig. 272b). The pain is always greater at the seat of 
fracture and may be referred along the course of the intercostal nerve 
(Fig. 271 ) at the seat of fracture when a forced inspiration is attempted, 
on account of the increased movement of the chest wall. 

Complications. — The complications of fractures of the ribs are those 
due to injury of the thoracic or abdominal contents. These complications 
are fairly frequent. 

Intrathoracic. — (a) Laceration of pleura and lung. The most com- 
mon indication of such a lesion is subcutaneous emphysema, first noted at 
the seat of fracture and rapidly spreading. This condition always denotes 



282 



TEEATISE OX FRACTURES 



puncture of the lung-. Instead of producing a subcutaneous emphysema, 
the air from the ruptured lung may escape only into the pleural cavity, giv- 
ing rise to a pneumothorax ; or there may also be some blood in the pleural 
cavity in addition to the air, causing a haemopneumothorax (Figs. 2J$, 
274). The lung may actually become compressed and collapsed by 
large quantities of air and blood in the pleural sac. When the emphyse- 
matous condition extends into the mediastinum and the interlobular cellu- 
lar tissue of the lung, the patient's condition becomes critical, (b) Peri- 




FiG. 273. — Compression injury of chest. Man caught under elevator. Injury consists of frac- 
ture of left fourth rib, which punctured the lung with resultant haemothorax. Note compensa- 
tory hyperdistention of right lung, or pneumothorax. 



cardial and heart injuries. These are very infrequent, except after very 
great violence, (c) Laceration of the intercostal artery is rather more 
infrequent than one would suppose. The subsequent hemorrhage is rarely 
severe enough to cause alarming symptoms, unless the site of fracture 
communicates with a wound into the pleura, (d) Traumatic asphyxia. 
This condition follows compression of the chest in conjunction with frac- 
ture or dislocation, and is characterized by a dusky, cyanotic discoloration 
of the skin of the head, face, neck, and upper part of the chest, accom- 
panied in the eyes by subconjunctival ecchymosis, usually limited to the 
interpalpebral space. This blueness appears immediately after the acci- 
dent and is probably due to minute capillary extravasations, (e) Hernia 



STEKNUM, BIBS, AND COSTAL CARTILAGES 



283 



of the lung. A few cases of this rare complication have been reported, 
notably by Wahl, Huguier, Weiss, and Volger. In most of the cases 
reported, the ribs involved were one or more of the first five ribs. 

Intra-abdominal. — The most frequent injuries of the abdominal 
organs seen as a complication of fracture of the ribs are rupture of the 
liver, spleen, stomach, or intestine, and laceration of the diaphragm. In 
such severe injuries, the abdominal lesion demands greater attention than 
that of the ribs. Abdominal section will probably be urgent. 

Diagnosis. — The diagnosis may generally be made from the subjec- 
tive and objective symptoms present; but may require fluoroscopic or 
rontgenogram examination for confirmation. In mild cases, the institu- 
tion of fracture treatment may be sufficient without wasting time or 
money for radiographic diagnosis. If pain on deep inspiration subsides 
within two or three days, it is likely that only muscular contusion or other 



Fig. 274a. 



Fig. 274ft. 
to 





Fig. 274a. — Cross-section of chest, showing normal relations of intrathoracic structures to the overlying 

ribs. 
Fig. 274b. — Diagrammatic representation of complications which may occur in fracture of the ribs. 
On the left side is shown the presence of subcutaneous emphysema from injury to the lung due to fracture 
of the ribs at (A). On the right side is shown the presence of haemothorax and compression of the lung 
following a fracture to the ribs at (D) and associated injury to the right lung. (Modified after Eisendrath). 

slight injury was present. The most frequent are localized pain and 
tenderness, crepitus, swelling, and restricted respiration. 

Prognosis.— This is generally favorable in the usual uncomplicated 
costal fractures. Union occurs in three to five weeks by interosseous 
and ensheathing callus, which often leaves an irregularity because perfect 
immobilization of the parts is impossible. When fracture of several adja- 
cent ribs has taken place, union often occurs not only between the frag- 
ments of each rib, but the several ribs are united by an exuberant callus. 
Hernia of the lung may occur after much displacement or comminution of 
fragments. Marked dyspnoea of the pneumothorax is often a very dis- 
tressing and at times fatal condition. The development of pleurisy, peri- 
carditis, or pneumonia makes the prognosis grave, but recovery after 
severe intrathoracic injuries often takes place. After fracture of the 
upper ribs, carrying heavy loads on the shoulders may be painful for a 
long time. 

Treatment. — Fracture of the ribs should be treated by reduction of the 



284 TEEATISE ON FEACTITKES 

fragments and immobilization. The surgeon should at the same time be 
on the alert to avert or relieve intrathoracic inflammation. This is espe- 
cially true in comminuted fractures of several ribs, such as occur from 
passage of vehicles over the chest and in accidents in falling walls. Re- 
duction of fragments may best be accomplished by forcible inspiration and 
manipulation. If the ends of fragments are depressed, it rarely may be 
advisable to resort to incision for reduction. In the majority of cases 
there is very little deformity, but perfect reduction is impossible. Im- 
mobilization should aim at splinting the parts so that thoracic breathing 
is limited. This is best accomplished by the application of a circular 



Fig. 275a- Fig. 2756. 







I 



**9 * » 



- 




« 



W 




Figs. 275a and 2755. — Method of application of the adhesive plaster swathe in the treatment of fractures 
of the ribs. External splinting of this character gives entire relief from pain by splinting the external 

respiratory muscles of the chest. 

swathe of adhesive plaster, six to eight inches in width, encircling the 
chest with its centre at the seat of fracture (Fig. 2j?). The patient 
should be standing with the hands resting on the head during its appli- 
cation. One end of the plaster is applied and fixed to the side of the chest 
opposite to the fracture, and is carried around the body. Its application is 
completed at the end of a forced expiration. Before applying this dress- 
ing all hair should be removed from the chest. Several narrow strips of 
adhesive plaster each overlapping the one below may sometimes be found 
more comfortable. The lowest should be applied first. In a few cases 
such constriction of the chest will be contra-indicated, especially if the 
patient has asthma or chronic bronchitis. In this instance the plaster may 
be applied half-way around the chest, thus limiting motion on the side 
injured only. 

Another form of dressing consists in the application of a firm binder 
of heavy muslin carried around the thorax and pinned down the front; 



STERXOL RIBS, AND COSTAL CARTILAGES 



285 




Fig. 276. — Bandage for fractured ribs. 



straps should be carried from its upper edge over the shoulders, like sus- 
penders, to prevent its slipping" downward. This circular dressing should 
be worn at least three weeks, after which a circular cotton roller bandage 
may be applied for one or two more weeks. 

The intrathoracic complications demand, as a rule, no special treat- 
ment unless they produce grave symp- 
toms. The cellular emphysema some- 
times present requires no attention, as 
the air is soon absorbed. Even when 
great extension of the emphysema oc- 
curs, no danger is to be apprehended, 
except when it extends into the medias- 
tinum and interlobular tissue of the 
lungs. Pneumo- and hamiopneumotho- 
rax and pleural effusion, if of alarming 
degree, call for aspiration. Extreme 
congestion of the lungs, with accompany- 
ing grave dyspnoea, should be relieved by 
venesection and the traditional treatment for pulmonary inflammations. 

Fractures of the Costal Cartilages 

These fractures occur most frequently near the costochondral junction 
and involve usually the seventh or eighth cartilage. The partially ossi- 
fied cartilages of the aged are more susceptible than those of the young; 
the changes taking place in advanced life are of a fibrinous character, 
and calcification and ossification are not common. The line of fracture 
is generally transverse, excepting when the break is an extension from a 
fracture of the sternum, when it may be longitudinal or diagonal 
in character. 

Etiology. — Many of these fractures are due to direct violence, al- 
though there are reported cases due to indirect violence and muscular 
action. 

Symptoms. — Deformity is the most constant symptom. In addition 
there is localized pain and at times a soft crepitus. The displacement of 
the fragments generally shows the sternal one to be displaced inward and 
vertebral one outward. 

Diagnosis. — This rests mainly upon the deformity and site of the 
lesion. 

Prognosis. — Is good. Union takes place not by cartilage but bv 
osseous or fibro-osseous tissue. This forms a bony callus around the ends 
of the fragments, and is a more or less similar union to that seen in 
fractures of the ribs. 

Treatment. — The treatment consists in replacement by manipulation, 
combined with forced inspiration. Immobilization is obtained in the same 
way as is used for fracture of the ribs. 



CHAPTER XIV 

FRACTURES OF THE CLAVICLE 

Anatomy. — The clavicle (Fig. 2//) or collar-bone is shaped like an 
italic f, and is composed of a body or middle portion, the sternal and 
the acromial extremities. The inner end articulates with the sternum 
and is firmly attached to the latter by the sternoclavicular ligaments and 
an interarticular fibrocartilage and to the cartilage of the first rib by the 
costoclavicular ligament. The outer end articulates with the acromial 
process of the scapula and is firmly fixed tt> the acromial process of the 
scapula by the acromioclavicular ligaments and also to the scapula by 
the coracoclavicular ligament, which is composed of two parts, the trape- 
zoid and the conoid. It is on account of the arrangement of the ligaments 
attached to the outer end of the clavicle that displacements of fragments 




Anterior border 
Fig. 277. — Right clavicle, upper surface. 

do not as a rule occur in fracture of its outer one- fourth. It isi developed 
from two ossific centres. That for the shaft appears very early in intra- 
uterine life, while the epiphysis for the sternal end does not show itself 
until the eighteenth or twentieth year and becomes united to the shaft 
about the twenty-fifth year. This must be recollected in suspected frac- 
tures near the acromion. 

Surface Markings. — The clavicle is superficial throughout its entire 
length. One can readily palpate the sternoclavicular and acromioclavicu- 
lar joints and note the distinct S-shape of the bone and the junction of its 
two curves at its middle, where fractures most often occur (Fig. 278). 
Beneath the clavicle are the subclavian artery and vein, which are at 
times injured in fracture of the bone. The brachial plexus also lies 
beneath the clavicle, being separated from it by the subclavius muscle. 
Its entire anterior surface can be felt from the sternal to the acromial 
end. In thin persons the middle of the bone may be readily grasped so as 
to demonstrate the presence of crepitus. 

Clavicular fractures are especially frequent during childhood; the 
mechanism which generally produces a dislocation at the shoulder-joint 
286 



FRACTURES OF THE CLAVICLE 



287 



in adults, namely, a fall upon the shoulder or a force transmitted from 
a fall on the hand, causes a fracture of the clavicle during childhood. 

Etiology. — Fractures of the clavicle may be the result of direct vio- 
lence, indirect violence, or muscular action. By far the most common 
cause, however, is indirect violence. Thus in falls upon the shoulder, 
elbow, or hand, while the arm is extended and the muscles held rigid, the 
force of the impact is transmitted to the clavicle, which constitutes the 




I 



> 




Fig. 278. — Palpation of clavicle; method of determining crepitus, abnormal mobility, 

and deformity. 

only bony connection of the arm with the trunk. A tendency to exag- 
gerate the curves of this doubly curved and twisted bone is thus produced, 
and the bone gives way as soon as the strain becomes too great. Cases 
have been reported by Malgaigne and others, in which the fracture was 
produced by bending of the clavicle over the first rib by sudden depression 
of the shoulder. Forcible compression of the shoulders may also produce 
a fracture of the clavicle by indirect force. 

Instances of fracture of the clavicle by direct force are those in which 



288 



TREATISE OX FRACTURES 




Fig. 279. — X-ray of shoulder joint. (Helferich.) 




\M 



! ^% 




Fig. 280. — Drawing to show the attachments of the coracoclavicular and 

coracoacromial ligaments and the reason for absence of displacement in 

fractures of the outer end of the clavicle. 



FBACTUKES OF THE CLAVICLE 



289 







Fig. 281. — Muscular relations in the clavicle and upper humeral region. 
(1) Trapezius; (2) deltoid; (3) cut edge of great pectoral; (4) sterno- 
clavicular-mastoid. 





Fig. 282. — Fracture of the middle third of the clavicle, direct violence. 



19 



290 



TREATISE OX FRACTURES 



the clavicle is directly struck by a blow or a falling object directed back- 
ward and downward or by the recoil of a rifle butt. 

Fracture by muscular action may be produced by vigorous sudden 
action, in which sudden contraction of the deltoid and pectoralis major 

a muscles occurs, as in lifting heavy 
weights, suddenly seizing a fixed ob- 
ject when one is falling, or violently 
using a tennis racquet. 

Varieties. — The outer part of the 
middle third is the most common site 
of fracture, but from its obliquity the 
line may extend into the outer or inner 
third. The frequency with which frac- 
tures occur at this region, as a result 
of indirect violence, is due to< the small 
diameter of the bone and the sharp- 
ness of the curve at this point. Com- 
minuted, multiple, or open fractures 
are rarely seen. Transverse and 
green-stick fractures are frequent in 
I children, with very little deformity, 

displacement of fragments, or lacera- 
tion of the periosteum. 

Symptoms. — Fractures of the mid- 
dle third (Figs. 282-285) present 
a characteristic symptom-complex. The usual deformity is produced 
by a tilting upward of the outer end of the sternal fragment while the 



FlG._ 283. — Fracture of the middle third of the 

clavicle by indirect violence, characteristic 

deformity. 




^H 



■ 



Fig. 284. — Fracture of the clavicle, junction of the middle and inner 

thirds. Characteristic displacement of fragments. Outer end of inner 

fragment is displaced upward; outer fragment inward and downward. 

inner end of the acromial fragment is carried inward underneath the 
sternal fragment. Thus the two portions of the clavicle form an angle 



FKACTUBES OF THE CLAVICLE 



291 




Fig. 285. — Fracture of middle third of clavicle, absence of displacement of fragments, 
produced by indirect violence. 



CLAVfCLE. 



SCAPULA 



ACROMION 

PROCESS 




HEAD of 
HUMERUS 



FlG. 286. — Shows typical displacement of fragments in complete fracture 
of middle third of clavicle. The inner fragment is pulled upward by the 
action of the sternomastoid muscle, while the outer fragment is carried 
downward, forward, and inward with the shoulder. Dotted lines show 
normal position of shoulder. 



292 TEEATISE OX FRACTURES 

with its apex upward; at times they may resemble a Y, or T. The 
shoulder is displaced forward, downward, and inward (Fig. 286). The 
projection upward of the outer end of the sternal fragment is due to 
the pull of the sternocleidomastoid muscle and the lifting force exerted 
by the outer fragment being thrust under it. The displacement inward, 
forward, and downward of the acromial fragment is due to the fact that 
the clavicle is the support which holds the scapula and the attached arm 
in its proper relation to the thorax (Fig. 287). Fracture of the clavicle 







Fig. 287. — Drawing to demonstrate tj-pical displacement of frag- 
ments in fracture of middle third of clavicle. 

removes this support, and, as a result, the scapula is rotated around the 
dorsolateral aspect of the chest, and the acromion depressed, by the weight 
of the upper extremity and the action of the serratus magnus, the pec- 
toralis major, and the rhomboideus muscle. Shortening of the clavicle 
may be determined by measuring from the acromion to the sternoclavicu- 
lar articulation and comparing this with the sound side. Shortening is 
great in oblique fractures with overriding, and may amount to one or 
two inches. In some transverse and incomplete fractures angular de- 
formity may be present in an upward and backward direction. In green- 
stick and subperiosteal fracture there may be no deformity. In all of 
these fractures the amount and the direction of the displacement are 
influenced by the continuance of the fracturing force, after rupture of the 
bone has occurred, and by the line of fracture. 

Displacement of fragments may be readily palpable and their outlines 
visible in many cases. Crepitus is determined by grasping the two frag- 



FKACTUBES OF THE CLAVICLE 293 

merits or, in children, by grasping the shoulder and by movement, which 
causes the fractured ends to rub against each other. Crepitus is not pres- 
ent in incomplete and in green-stick and rarely in subperiosteal fracture. 

Fractures of the outer third (Figs. 288 and 289) come next in fre- 
quency to fractures of the middle third, and are as a rule irregularly 
transverse in direction. This displacement is dependent upon the loca- 
tion of the line of fracture. When it is in the area of the attachment of 
the coracoclavicular ligament (Fig. 280), little if any displacement of 
the fragments takes place; but when the line of fracture is beyond the 
attachment of this ligament, the inner end of the outer fragment may be 
tilted upward by the trapezius, and the outer end of the inner fragment 
drawn downward and inward by the attached fibres of the deltoid and 
portion of the pectoralis major muscles. Considerable angular displace- 
ment is possible. 

Fractures of the inner third (Fig. 290) are very infrequent. The 
deformity when present consists in a displacement downward and for- 
ward of the inner end of the outer frag- 
ment, or angular distortion of both frag- 
ments in the same direction. Displace- 
ment is generally limited by the attachment 
of the costoclavicular ligament below and 
the sternocleidomastoid muscle above. 
Most fractures here are due to direct vio- 
lence. Fig. 285 represents a case due to 
indirect violence — a fall upon the shoulder. 

The local deformity in fractures of the 
clavicle at its various parts has been de- 
scribed. In addition crepitus may be ob- 
tained except when the fragments are im- 
pacted, or widely separated, or when the l^J^ ^thl ^MSuSTfigS! 
fracture is incomplete. There is swelling ment and no dls Sur™ ent ° f fragments 
and ecchymosis at the seat of fracture; 

generally inclination of the head toward the affected side in fractures 
of the middle third, displacement to relax the sternomastoid muscle, and 
a characteristic attitude with inability to raise the arm. This loss of 
function is due to pain, and prevents the raising of the hand to the head 
or placing the arm in marked abduction. 

In children fractures of the clavicle are often incomplete, or green- 
stick, and are unattended by deformity, crepitus, or displacement. These 
fractures are often overlooked unless the child complains of pain and 
refuses to move the arm voluntarily. Examination will often detect local- 
ized tenderness, swelling, and slight irregular deformity, generally ante- 
riorly or upward; and in the course of a few days or a week there will 
be a circumscribed spindle-shaped swelling due to the formation of 
ensheathing callus. 




294: 



TEEATISE OX EEACTUEES 



In fractures of the outer third without deformity or displacement of 
fragments, crepitus may be elicited, as a rule, by careful pressure on the 
upper surface of the outer fragment, while grasping the middle of the 



Fig. 289a 




Fig. 289a. — Fracture of tip of outer end of clavicle. This partakes of the nature of a tear-fracture 

from force exerted through the acromioclavicular ligament. 
Fig. 2896. — Fracture of the outer end of the clavicle. Fragments are held together by the attachments 

of the coracoclavicular ligaments. 




Fig. 290. — Fracture of the inner end of the clavicle. 



(Courtesy of Dr. P. G. Skillern, Jr.) 



clavicle firmly and making motion. When crepitus cannot be elicited in 
this manner the presence of a fracture may be diagnosed by localized 
pain, ecchymosis, and swelling. Erdman considers that the diagnosis may 



FRACTUKES OF THE CLAVICLE 



295 



be made in doubtful cases by the lessened transmission of respiratory 
sounds to points on the clavicle beyond the seat of fracture. Radiographs 
will usually settle the diagnosis in doubtful cases. 

Fractures near the acromial end may simulate supra-acromial dislo- 
cation. In green-stick, subperiosteal, or incomplete fractures the forma- 
tion of callus may simulate a syphilitic periostitis, A case has recently 
been treated by Doctor Kelly in which the fracture resulted from a slight 
fall upon the elbow in a patient having a syphilitic lesion of the clavicle. 

Complications. — Open fractures are rare except in cases in which 
the violence has been direct and great and in those in which there are 
associated injuries. Complications that may occur are laceration of the 
brachial plexus, the subclavian artery, and sub- 
clavian or internal jugular veins, and puncture of 
the pleura or apex of the lung. The late compli- 
cations are those due to pressure of fragments or 
excessive callus. 

Prognosis. — Union generally takes place in 
children in fifteen to twenty-one days and in adults 
from twenty-one days to six weeks. Non-union is 
rare and when it does occur only a moderate degree 
of disability persists. Moderate deformity at the 
seat of fracture does not interfere greatly with the 
subsequent use of the arm. Impairment of function 
from the pressure of exuberant callus on the blood- 
vessels and nerves behind the clavicle is more often 
the result of the use of a large axillary pad during 
the treatment rather than direct pressure by callus. 
The normal abduction of the arm may be lessened 
by union of callus to the coracoid process. 

Treatment. — Many cases of fracture of the clavicle are accompanied 
by very little deformity. This is especially so in the subperiosteal and 
green-stick fractures seen in the middle third in children, and in fractures 
of the outer third of the clavicle at the attachment of the coracoid-clavicu- 
lar ligament. In these cases a simple dressing to restrict too free use of 
the arm is all that is necessary. A triangular handkerchief sling to sup- 
port the elbow, or a knotted sling made of a moderately wide, strong 
muslin bandage may fulfil the indications. Reduction of the deformity in 
green-stick fractures may often be readily accomplished; when the 
displacement is slight, reduction is not advisable. In such cases a small 
pad over the seat of fracture held in place by adhesive plaster, and the 
use of a sling with the arm bound to the side, or the application of the 
claviculo-humeral dressing meet the indications for treatment (Figs. 
293a and b). The pad placed over the site of break will retain its place 
well if covered with adhesive plaster with the rubber side next to the 




Fig. 291. — Knotted sling 
used in dispensary. 



296 



TREATISE OX FEACTUEES 



skin. It is in cases of complete fracture of the clavicle at the middle 
third, attended by marked deformity, that retention of the fragments 
in their correct position after proper reduction often becomes difficult. 
Fortunately the permanent deformity often resulting is more of a cosmetic 
defect than a permanent disability. 

Correction of the deformity in complete fractures of the middle third 
is attempted by grasping the arm and shoulder and endeavoring to swing 
the scapular backward around the posterior aspect of the chest toward 



- -, 




Fig. 292a, — Rest and gravity treatment of fracture of right clavicle. First position: The arm hangs 
naturally at the side of the bed until displacement becomes corrected. (Warbasse's Surgical Treatment, 

W. B. Saunders Co.) 

the median line of the back. By this manoeuvre the shoulder is carried 
upward, outward and backward, and the outer or acromial fragment is 
brought into its normal position. At the same time moulding of the frag- 
ments is performed, and in most cases perfect reduction of the fragments 
may be accomplished. The difficulty is in maintaining reduction until 
firm union has been established. 

The following methods of treatment are recommended : 
Dorsal Recumbency. — The flexed forearm and arm are held near 
the chest by a circular bandage. The patient is then placed upon a firm, 
level mattress, with his head raised on a pillow and turned toward the 



FRACTURES OF THE CLAVICLE 



297 



injured side, to relax the sternomastoid muscle; and a small sand-bag is, 
placed over the acromion to hold the shoulder in the desired direction, 
The forearm may be held across the chest with a bandage looped around 
wrist and fastened to opposite side of the bed. This postural form of 
treatment in bed should be persisted in for from ten to fourteen days 
and is irksome only during the first few days. At the end of that time 
the patient may be allowed to get up, as a rule, and continue treatment 
bv one of the ambulatory methods, because the fragments show usually 




Fig. 292b. — Rest and gravity treatment of fracture of clavicle. Second position: The forearm rests 
on pillow which should be low enough to impose some traction upon the shoulder. (Warbasse's Surgical 

Treatment, W. B. Saunders Co.) 

less tendency to displacement after muscular spasms have been lessened 
and the fragments surrounded by reparative exudates. Dorsal recum- 
bency is as a rule recommended only to women who dislike clavicular 
deformity because they are required at times to* go in public with the neck 
exposed. In men the deformity often seen after a broken clavicle is not 
objected to if good function is promised. 

A convenient modification of the recumbent method is that recom- 
mended by Couteau. First, the patient lies for an hour and a half on his 



298 



TREATISE OX FRACTURES 



Fig. 293a. 





H 






back with arm of injured side hanging over the edge of bed. Gravity 
and rest thus applied correct deformity by reducing the fragments. Later, 
the arm, still hanging in abduction, but with elbow flexed at a right angle, 
is supported on a chair or stool slightly lower than the level of the elbow. 

This second position may be main- 
tained by a wrist sling attached to the 
side of the bed. The support of the 
forearm is adjusted to give a little 
traction on the shoulder by gravity. 
This position is maintained day and 
night for seven days. A swathe may 
be carried around the chest of the 
recumbent patient and fastened to 
the side of the bed opposite to the in- 
jured clavicle to keep up countertrac- 
tion and prevent the patient falling 
out of bed. After the lapse of about a 
week in this posture, the arm is 
FlG - 293b - brought down to the patient's side 

and he remains in bed a few days 
longer still in the supine position ; but 
with a pillow between his shoulders 
to steady the scapula. Ten or twelve 
days after injury the reduced and 
partially consolidated fracture is 
sufficiently held by callus to permit 
the upright posture to be assumed 
and careful walking to be permitted. 
A mere sling to support the forearm 
should be enough dressing after that 
time, if the injured person is reason- 
FlG - 2 93c ably careful to avoid strain on the 

fracture from abrupt movements of 
the arm. 

Sayre Dressing or Its Modifi- 
cations (Figs. 293 and 294). — This 
fracture dressing is advisable for 
ambulatory treatment in late ado- 
lescence and in adult life. It is not 
practicable in young children, in 
short people, or in women with large 
breasts. The skin of the chest should 
be shaved if hairy, and the chest, 
arm, and forearm thoroughly washed 
ha ^^^^F^^%^Sr^! g - "with soap and water, rubbed with 



.. 



1 





FRACTUBES OF THE CLAVICLE 



299 



alcohol, and well powdered. Especial attention should be given 
to the axilla. All apposed portions of the skin should be carefully 
protected by several layers of lint or sheet- wadding. After the frag- 
ments have been completely reduced, a thin pad of gauze or cotton 
wadding is placed in the axilla, of the injured arm and a cuff of lint 
three inches in width is placed about the upper arm. Over this the end of 
a three and a half feet long strip of adhesive plaster, three inches in 
width, is passed in the form of a loop around the arm, care being taken 
that it is not so tight as to constrict the vessels. The loop at the end may 
be made by stitching the bent strip of plaster to itself. The elbow is 
drawn well back and fixed in this position by the plaster being carried 



Fig. 294a. 



Fig. 2946. 




h 





■ 




Fig. 294. — Finished Sayre dressing for fracture of the clavicle. 

around the entire chest from back to front, stopping at the anterior axillary 
line of the injured side. The elbow is flexed and the forearm laid upon 
the front of the chest with the palm on the opposite breast. A second 
adhesive strip, three inches in width, with a hole cut in it for the ole- 
cranon, is then applied. Beginning on the posterior surface of the upper 
arm it is carried down to the olecranon, over the extensor surface of the 
flexed forearm and hand, and over the opposite shoulder, so that the end 
may lie upon the dorsum of the scapula of the uninjured arm. Before 
fixing the strip over the sound shoulder and back, the forearm and hand 
should be drawn toward the sound shoulder with a fair amount of force. 
The loop of the first strip acts as a fulcrum and the shoulder of the injured 
side is thereby carried upward, outward, and backward. The dressing- 
is finished by carrying' a muslin bandage around the chest and over the 
broken clavicle. This holds the arm against the ribs and increases the 
support over the reduced fragments. A modification of the Sayre dress- 
ing is the addition of a third strip of adhesive plaster beginning at the 
elbow, running upward over the seat of fracture, and down the posterior 
part of the arm. A small folded piece of lint is placed between the seat 



300 



TREATISE OX FRACTURES 



of fracture and the adhesive plaster. Ordinarily in most individuals this 
dressing may remain in place for two and a half to three weeks, after 
which time it may be replaced by a sling for the forearm and a circular 
bandage fixing the arm to the chest wall. The patient will, however, be 
much more comfortable if the dressing is renewed about every six or seven 
days and reapplied in the same manner after bathing the skin with alcohol 
or soap and water. 

The Claviculo-humeral Bandage Dressing (Fig. 295). — In early 
childhood and stout individuals the Velpeau dressing with certain modifi- 
cations is the one of choice. All apposed skin surfaces should be care- 
fully protected. After complete reduction the elbow of the injured side 
is brought well to the front of the chest and the hand placed upon the 



Fig. 295a. 



Fig. 2956. 




Figs. 295a and 2956. — Photographs to show application of claviculo-humeral bandage in fracture of 

the clavicle unattended by any great degree of deformity. The skin contact surfaces should be well 

separated by sheet-wadding before applying the bandage. 

opposite shoulder. A roller bandage is carried from the scapula of the 
well side obliquely over the back of the injured shoulder, over this, down 
the outside of the arm, under the elbow, across the chest to the opposite 
axilla, and to the point of starting. After a sufficient number of turns have 
been made to support the arm, the bandage is carried around the arm and 
chest by circular turns from the elbow upward to the shoulder. This 
dressing is reinforced by the application of a light plaster-of -Paris case 
(Fig. 41) or a silicate of sodium dressing. Before the dressing has set 
the patient is placed upon his back, the shoulders are pressed backward 
and held in this position until the dressing has hardened. In some cases a 
small pad should be placed over the outer end of the sternal fragment 
before this dressing is applied. The patient is then allowed to walk about 
and, if advisable, a window may be cut in the dressing at the end of a 
week to observe the position of the fragments. In cases attended with 
considerable deformity this dressing should be worn four weeks. 

Warbasse uses a neat and comfortable dressing of three strips of 
adhesive plaster, a muslin binder, and two gauze pads. A pad of gauze 
is placed in the axilla and another on top of the reduced clavicular break. 



FBACTUEES OF THE CLAVICLE 301 

A strip of adhesive plaster is carried around the arm near the shoulder, 
as in the Sayre method; the remainder of the strip crosses the back over 
the lower angle of the scapula and around the chest under the other arm 
to the injured side. Over this adhesive plaster is pinned a muslin binder 
six inches wide. The elbow is flexed at a right angle and the forearm 
laid across the chest. A second adhesive strip is carried from the back 
of the sound axilla across the back, over the pad on the clavicle, down 
the front of the chest, under the forearm of the injured side, upward 
behind the axilla of the injured side over the clavicular pad to the front 
of the axilla of the sound side. This dressing keeps the arm and shoulder 



Fig. 296. Fig. 297. 






Figs. 296 and 297. — Stimson's " ftgure-of-8 " dressing for fracture of acromial end of the clavicle. Fig. 
296 shows "figure-of 8" adhesive plaster, pad over seat of fracture, and wrist-sling. Fig. 297 shows 

complete dressing. 

backward, steadies the axillary pad and the scapula, presses the upper arm 
against the chest wall below the pad, thus drawing the acromial fragment 
of the clavicle outward. It also makes a moderate pressure on the frag- 
ments at the site of the break and prevents angulation upward and for- 
ward. A sling to support the wrist is made by using a loop of adhesive 
plaster around the forearm and carrying the end of this plaster over 
the fracture and pinning it at the patient's back to the muslin binder. 

In fractures of the outer end of the clavicle attended by displacement 
of fragments, the most satisfactory dressing is Stimson's " figure-of -8," 
made of adhesive plaster (Fig. 296). 

Operative Treatment. — In all cases in which deformity recurs in, spite 
of all measures made to maintain reduction, the seat of fracture should 
be exposed under strict asepsis, and the fragments held with chromic 
catgut sutures after suitable drill holes have been made. A small drill 
or nail may be used to pin the fragments together in reduced position. 
This may be introduced through a mere puncture in the skin, and with- 



302 TEEATISE ON FRACTURES 

drawn after a couple of weeks. After the wound has been closed and a 
sterile dressing applied, a bandage, reinforced by a plaster-of-Paris case, 
should be applied. 

Summary of Treatment 

In green-stick fractures and when there is little displacement, a 
simple retentive dressing, such as a sling to support the entire arm and 
hand, with perhaps a pad over the seat of fracture held in position with a 
strip of adhesive plaster. The claviculo-humeral dressing is excellent. 

If much displacement and in women fearing disfigurement, reduction; 
should be followed by dorsal reeumbancy, as described, to> hold the lower 
angle of the scapula against the ribs for about two weeks; then ambula- 
tory treatment for about three weeks. 

In other cases ambulatory treatment by a Say re, claviculo-humeral 
or Warbasse dressing, or some modification of them. 

In very troublesome fractures, subcutaneous nailing with Roberts 
drill-nail method, or operative fixation with absorbable or wire sutures. 

If non-operative treatment has left undesirable deformity, removal 
of prominence with chisel. 



CHAPTER XV 



FRACTURES OF THE SCAPULA 

Anatomy .—The scapula (Fig. 299) or shoulder-blade is a large, flat, 
irregular bone forming the posterior part of the shoulder girdle. It 
articulates with the clavicle and humerus at its outer extremity and rests 
upon the posterior surface of the thorax, being separated from it by 
muscles alone. It is a triangular-shaped bone, having two surfaces, the 
ventral and dorsal, three angles, the superior, the inferior, and the lateral, 
and three margins, the internal or vertebral, the external or axillary, and 
the superior. The dorsal surface is divided into two parts, called the supra- 
and infraspinatus fossae, by the spine. The superior border has a well- 




Fig. 298. — Development of scapula: (A) at eighth foetal month; (B) toward end of first year: (C) from 

fourteen to fifteen years; (D) from seventeen to eighteen years; (E) about twenty years, (a) Chief 

centre; (b) for coracoid process; (c) for acromion; (S) for inferior angle; (e) additional for acromion; 

(/) for vertebral border. (Piersol.) 

marked notch, the suprascapular notch, and external to this a hook-like 
process extending forward and outward, the coracoid process. From the 
external angle there is a moderate constriction called the neck and, exter- 
nal to this, an expanded portion, the head, the outer surface of which is 
smooth and concave. This is termed the glenoid cavity and is the articular 
surface for the head of the humerus. The external process of the spine 
which passes over the neck and glenoid cavity from behind and above is a 
strong, irregular, broad process called the acromion. It contains a facet 
internal to its apex for articulation with the clavicle. 

The scapula is developed from seven ossific centres, one for the 
body, two for the coracoid process, two for the acromion, one for the 
posterior border and one for the inferior angle. The centres for the 
acromion, the posterior border, and the inferior angle appear at about 
16 years of age, and unite with the body between 22 and 25 years. That 
for the body appears at two months and those for the coracoid process 
at one year and at seventeen years. 

303 



304 



TREATISE OX FRACTURES 



Surface Markings. — The scapula may easily be palpated, especially 
in thin individuals. The borders, angle, and spine may be outlined by 
flexing the elbow and placing the hand of the side to be examined on the 
opposite shoulder (Fig. 300(7) . The inferior angle, the superior angle, 
the vertebral and axillary borders may be felt readily, and the changes 
in their relation with the spine noted during abduction of the arm. The 
upper border is not so successfully palpated. The acromion and spinous 
processes may be readily felt ; the coracoid process, while not noticeable on 
inspection, is easily felt about one inch below the clavicle (Fig. 3006). 
The acromion process may be used as a fixed point in estimating suspected 



Coracoid process 
Acromion 




Axillary border 



Superior angle 



f) , '/;)^\ Superior border 

Suprascapular notch 

V 

\ Wf '/$ Jt—Vertebral border 

*V y \ ■ '.' / j — Sub-scapular fossa 



v AVw 



tendinous 

attachments 



Inferior angle 



Fig. 299. — Right scapula, anterior view. 

shortening of the humerus, the external condyle of the lower end of that 
bone being utilized for the other fixed point. The two upper extremities 
should be placed in the same relative position and measurements between 
these points carefully noted. 

Fracture of the scapula may occur in any part of the bone ; namely, the 
body, the superior angle, the inferior angle, the spine, the acromion, the 
neck, the coracoid process, and the rim of the glenoid cavity. 

Fracture of the Body of the Scapula— Etiology. — The body of the 
scapula is, on account of its position and mobility and its splinting by 
muscular masses, well protected against ordinary forms, of accidental 
injury. Fracture when it does occur is usually the result of direct violence, 
as from falls, street accidents, blows upon the shoulder, and impacts from 
heavy falling objects. Severe contusion of the soft parts, as a rule, accom- 
panies this injury. 



FKACTUKES OF THE SCAPULA 



305 



Varieties. — The fracture may be single or multiple, and the lines may 
be transverse or oblique. Comminution of fragments is frequent. Open 
fractures of the body are rare, excepting when due to gunshot or other 
penetrating wounds. Displacement of fragments may be due to the frac- 
turing force or to the pull exerted by the serratus magnus and teres 
major muscles ; hence the deformity may be by angulation, overriding, 
or separation. 

Symptoms. — The symptoms consist of localized pain, tenderness on 
pressure, abnormal mobility, crepitus, ecchymosis, and diminished func- 
tion. Crepitus and increased mobility may be demonstrated by placing 
the hand of the injured side on the opposite shoulder, thereby making 



Fig. 3000. 



Fig. 300b. 




Fig. 300a. — Method of palpation of suspected fracture of scapula. 
Fig. 300&. — Method of palpation of coracoid processes of the scapulae. 

the lower angle prominent, or by placing the forearm behind the thorax 
on the injured side. Pain may be elicited by abducting or raising the arm. 

Prognosis. — In fracture of the body of the scapula union occurs in 
three to four weeks. Accurate apposition of the fragments is not always 
possible and union occurs often with overriding and excessive callus. 
Inflammatory processes or exostoses in the bursas close to the joint cap- 
sule may be followed by permanent disability. 

Treatment.— After reduction, the approximation of the fragments is 
best maintained by immobilization and splinting. This is accomplished by 
the employment of a moulded and padded gypsum case over the scapular 
region, held in place by adhesive plaster ; and by immobilizing the entire 
upper extremity with a firmly fitting claviculo-humeral bandage. This 
dressing may be reenforced by a few turns of a gypsum bandage. Addi- 
tional steadiness may be given to the fracture by carrying a wide strip 
of adhesive plaster over the clavicle and vertically down over the body 
20 



306 TREATISE OX FRACTURES 

of the scapula, and applying across this a second strip over the site of the 
fracture. The arm may then be bandaged to the chest with a pad in the 
axilla and the forearm hung in a sling supporting the elbow. 

Fractures of the Superior Angle of the Scapula (Fig. 301) — Eti-, 
ology. — Fractures of the superior angle are very rare. Few have been 
observed or reported except in conjunction with fractures of the spine or 
body of the scapula. They are usually the result of direct violence. 

Varieties. — The lines of fracture may involve the spine or extend 
into the subspinous fossa,, as in that recorded by Hamilton. Displacement 
may occur upward due to the pull of the levator scapulae muscle. 




Fig. 301. — Left scapula; stellate fracture of the superior angle. Starting from a 
point in the spine 2 cm. from the posterior border, fracture lines passed upward, 
backward to the posterior border, and downward. A fragment 2x5 cm. was 
detached from the posterior border. The fragments are well united, and the 
callus is abundant. (Mutter Museum, No. 1247.) 

Symptoms are similar to those described for fracture of the body. 
Displacement of the fragment upward would be readily palpable. 

Treatment. — Immobilization of the arm by claviculo-humeral bandage 
after fixing the scapula by a padded gypsum splint, as described in fracture 
of the body. 

Fractures of the Inferior Angle of the Scapula — Etiology. — Generally 
due to direct violence. Cases have been reported in which the fracture 
was the result of muscular action, as in wrestling or catching oneself 
with the hand while falling. 

The line of fracture is more or less transverse, and there is generally 
displacement of the lower fragment forward and upward, due to the pull 
of the serratus magnus and teres major muscles. 

Symptoms. — Pain, tenderness on pressure, abnormal mobility, crepitus, 
and displacement forward and upward of the detached lower angle with 
moderate overriding of the fragments will probably be found. Marked 
disability of the arm combined with apparent shortening of the bone 
measured from the spine to the lower angle is also present. 

Treatment. — The actual displacement may be partially overcome by 



FBACTUBES OF THE SCAPULA 



307 



bringing the elbow forward across the chest and fixing it here by means 
of the claviculo-humeral bandage. Union occurs in three to four weeks. 
After the third week the forearm may be placed in a sling and the arm 
fixed to the chest by a circular bandage. 





Fig. 302. — Fracture through spine of scapula. 



Fractures of the Spine of the Scapula (Fig. 302) — Etiology. — Frac- 
tures here are more or less frequent on account of the exposed position 
of the scapular spine, and are the result of direct violence. 

Varieties. — The line of fracture may involve only a portion of the 
spine or it may cause a com- 
plete separation, involving 
the spine at the base of 
the acromion. 

Symptoms. — Fractures of 
the spine may be recognized 
clinically by tenderness on 
pressure, crepitus, and abnor- 
mal mobility in the region of 
the spine, and some irregu- 
larity of outline. 

Treatment.— T h i s con- 
sists in immobilization of the 
parts by a padded gypsum 
splint and an overlying cla- 
viculo-humeral bandage. 

Fractures of the Acro- 
mion — Etiology. — Fractures 
of the acromion may be the 
result of direct violence. 
They also occur in conjunc- 





Br * 

w 


' *» 




{ 4 


A Bo 


P" kz ""~^~"' 


... "••-■>• -«««---i*i. ^M 



Fig. 303. — Right scapula; comminuted fracture of the base 
of the acromion process; union. One line of fracture passed 
transversely 5 cm. from the apex of the acromion. The 
other passed at a right angle to it from its centre toward the 
border. Union is complete on the under surface, on the outer 
surface the fracture lines are marked by deep indentations. 
(Mutter Museum, No. 1247.40-) 



308 



TREATISE OX FRACTURES 



tion with dislocation of the upper end of the humerus, and may without 
dislocation arise from hyperabduction of the arm. They may be the 
result of indirect violence, such as falls upon the hand or elbow or by the 
force, acting through attached ligaments, resulting in a sprain- fracture. 
Varieties. — Fracture occurs at the base of the acromion (Figs. 303 
and 304) and close to the point of articulation with the clavicle. Sprain- 
fracture (Fig. 305) and separation of the acromial epiphysis also are 
seen (Fig. 306). The two centres of ossification for the acromion appear 




Fig. 304 



. — Fracture through base of acromial process of scapula. 



about the sixteenth year, and ossification is not complete until from the 
twenty-first to the twenty-fifth years. 

Symptoms. — The lesions may be obscured by absence of deformity 
and swelling of the soft parts. Flattening of the shoulder is produced 
when the acromion is fractured at its base and is due to the weight of the 
arm pulling the fragment downward and inward. In fracture of the tip 
of the process little or no deformity is present and crepitus may be 
obtained by grasping the elbow while the shoulder is pushed upward. 
Inability to abduct the arm is generally present. Crepitus may be obtained 
only by hyperabduction of the arm (Fig. 307). 

Prognosis. — Fibrous is more common than bony union, and is due 
usually to inability to secure close approximation of the fragments. This is 



FRACTURES OF THE SCAPULA 



309 



especially so in fractures at the base of the process. Not much disability 
is liable to follow imperfect union. 

Treatment. — The indication for treatment is to immobilize the arm 
and at the same time force the head of the humerus well up against the 
scapula. These indications are met by the application of a firmly applied 



Fig. 305. 




I 







Fig. 306. 

Fig. 305. — Sprain-fracture of acromial process of scapula. 
Fig. 306. — Separation of the epiphysis of the acromial process of the scapula. 

claviculo-humeral bandage, reinforced by a few turns of a gypsum band- 
age (Fig. 308). Adhesive plaster strips holding the elbow pushed 
upward and the acromion downward may be serviceable. Pads to pre- 
vent pressure sores should be adjusted under the plaster at the seat of 
fracture and upon the olecranon. Warbasse has had satisfaction with 
a dressing consisting of a short band of adhesive plaster, placed over 
a pad on the inner fragment, with the ends hanging down in front and 



310 



TREATISE OX FEACTUEES 



behind the shoulder. These ends are united by rubber webbing or bands 
to a similar adhesive plaster strap placed under the flexed elbow. The 
upper arm is then fixed to the chest with a wide bandage and the forearm 
supported in a sling. 




Fig. 307. — Method of determining abnormal mobility and crepitus in fracture of 
the acromial process of the scapula by forced hyperabduction of the arm. 




Fig. 30«. — Dressing to immobilize shoulder in 
fracture of scapula. 




Fig. 309. — Lines of fracture of the 
scapula. 



If the deformity is great, the best results will be obtained by treating 
the patient in bed on a flat, firm mattress, with the arm held in marked 
abduction so as to relax the deltoid, which is the displacing muscle. 

Fractures of the Neck of the Scapula — Varieties. — Fractures of the 
so-called anatomical neck that is immediately behind the glenoid cavity 
and parallel with it are practically unknown. Fractures of the surgical 



FEACTUEES OF THE SCAPULA 



311 



neck (Fig. 311) are of three varieties: The fracture line in one passes 
behind the coracoid process downward from the suprascapular notch to 
the axillary border, and the coracoid process is separated from the body 
of the scapula ; in the other the fracture line begins in front of the coracoid 
process, passing down to the axillary border, and the coracoid process 
remains attached to the body of the scapula. These fractures are very rare. 
A third variety is that in which there is breaking off of the external angle 
of the scapula as a whole. The articular fragment includes not only the 



Pig. 310. 



-Diagram of subcoracoid dislocation of the humerus, 
indicated by the dotted lines. 



The long axis of the humerus is 



glenoid neck, but also the coracoid and acromion processes. Such an 
instance has been cited by Poland. Fractures of the neck are liable to 
be mistaken for fracture of the anatomical neck of the humerus or 
luxation of the humerus under the coracoid process. 

Etiology. — The cause of these fractures is generally a fall or blow 
upon the shoulder. Farabeuf considers that this fracture may be pro- 
duced by a blow upon the posterior aspect of the head of the humerus 
when there is outward rotation of the arm, thereby making the anterior 
portion of the capsule tense; or, if the arm is directed backward, a fall 
upon the elbow may produce a similar result. 

Symptoms. — These consist of flattening of the shoulder prominence 



312 



TEEATISE OX FEACTUEES 



of the acromion, loss of voluntary motion of the arm, crepitus after 
reduction, and recurrence of the deformity when the arm is allowed to 
drop from the elevated position. The deformity consists in sinking of 
the outer fragment of the scapula with the attached humerus (Fig. 312a). 
This flattening is especially seen if the deltoid muscle has lost its power 
from the circumflex nerve being involved in the injury. At times the 
edge of the fractured surface of the scapula may be felt through the 
axilla. When the line of fracture begins at the suprascapular notch, the 




Fig. 311. — Fracture of the surgical neck of the scapula. 

relation of the coracoid process with the head of the humerus is unaltered, 
but when the coracoid process remains attached to the body of the scapula 
these relations are changed. Forced elevation of the arm will often 
determine crepitus (Fig. 312M. 

Diagnosis. — The condition should be differentiated from acromio- 
clavicular luxation and deltoid paralysis, from the drooping of the 
shoulder at times seen after reduction of dislocations of the upper end 
of the humerus, and from dislocation of the head of the humerus. The 
fracture through the so-called surgical neck of the scapula, in which the 
coracoid process and the glenoid portion of the bone both are contained 
in the external fragment, gives a deformity of the shoulder quite similar 



FRACTUBES OF THE SCAPULA 



313 



to that in subcoracoid dislocation of the head of the humerus. The 
differential points are that in fracture the arm does not hang with its 
axis away from the chest, has its mobility increased and not suddenly 
brought to a standstill as in dislocation, and there is, crepitus felt by the 
examiner. In addition there is felt in the axilla a mass consisting of 
the glenoid and coracoid processes and the head of the humerus in one 
mass. Even an axillary luxation does not cause such a mass in the 
axilla. The deformity in fracture of the scapula recurs when support 
is discontinued. 

Treatment. — The indications in the treatment of these injuries is to 



Fig. 312a. 



Fig. 3126. 





Fig. 312a. — Drawing to show the displacement of fragments in fracture through the neck of the scapula. 

(1) Cut edge of deltoid; (2) biceps; (3) cut edge of deltoid. 
Fig. 3126. — Method of determining crepitus and abnormal mobility in fracture of the neck of the scapula 

by forced elevation of the shoulder. 



elevate the arm and keep it abducted with the elbow drawn slightly back- 
ward and to produce counter-pressure upon the acromion end of the 
clavicle. This is best accomplished by a claviculo-humeral dressing, with 
a moderate pad in the axilla and the entire bandage reinforced by a gypsum 
case. Union takes place with a moderate amount of displacement of the 
fragments, and may be followed by some impairment of motion dependent 
upon the amount of periarticular callus present. 

Fractures of the Coracoid Process — Etiology. — Uncomplicated frac- 
tures of the coracoid process are very rare. They are most often seen 
as complications of luxation of the head of the humerus, or of coincident 
injury to the clavicle, ribs, or other portions of the scapula, occurring 
therefore from indirect or direct violence. A few cases of fracture by 



314 



TREATISE OX FRACTURES 



muscular action (Fig. 313), as in wringing clothes, throwing a ball, or in 
forced supination, have been observed. 

Varieties. — The line of fracture is usually at the base of the process, 
or it may be the epiphyseal line, being in the latter instance an epiphyseal 
separation. Longitudinal splitting of the process has been reported. 

Symptoms. — In the absence of displacement of the process, the symp- 
toms noted are pain, localized tenderness, crepitus, and ecchymosis. Pain 
is increased on deep inspiration and on elevating the arm, due to the pull 
of the pectoralis minor muscle, and also- on flexion of the supinated fore- 
arm from the pull of the short head of the biceps muscle. Displacement 
of the coracoid process is generally limited by the action of the attached 




313. — Tear-fracture of epiphysis of coracoid process of scapula. 



muscles and the coracoclavicular ligament. When the latter is torn, the 
process may be displaced downward and inward, due to the pull of the 
coracobrachial, the biceps, and pectoralis minor muscles. The presence 
of coincident injuries of a grave nature will often obscure the symptoms 
of fracture of the coracoid and render its early diagnosis impossible. 

Treatment. — The arm should be placed in a position of hypernexion 
and the hand midway between pronation and supination. This is best 
accomplished by a modified Velpeau bandage reinforced by a few turns 
of the gypsum bandage. 

Fractures of the Rim of the Glenoid Cavity — Etiology .—Fractures of 
the rim of the glenoid cavity are seen occasionally as a complication of 
luxation of the upper end of the humerus. They are the result of moder- 
ate violence acting through the head of the humerus either from a direct 



FBACTUBES OF THE SCAPULA 315 

fall upon the shoulder or upon the elbow or hand, when the arm is in a 
position of hyperabduction. 

Varieties. — The following varieties have been noted : fracture of the 
inner rim of the articular surface in a longitudinal direction ; fracture of 
the outer or lower border involving a part of the neck (v. Bruns) ; a com- 
minuted or stellate fracture line involving the glenoid cavity and the neck 
and part of the body (Poland, Flower). 

Symptoms. — Persistence of crepitus after a reduction of a luxation 
of the head of the humerus, and a tendency toward a recurrence of the 
luxation on the removal of a retentive dressing" are significant of fracture 
of the rim of the glenoid. Other symptoms will be pain on motion, swelling 
about the joint, and ecchymosis. There may occur a late limitation of 
motion, and in some cases ankylosis of the joint, due to union of the frag- 
ments with the head of the humerus. A radiograph should help in making 
an early diagnosis. 

Treatment. — Immobilization with the claviculo-humeral dressing until 
union has occurred should be the line of treatment. After this has 
occurred massage and passive motion should be carried out, so as to 
prevent the formation of ankylosis. 

SUMMARY OF TREATMENT 

Overcome deformity by reduction; steady the seat of fracture by 
appropriate position of arm, in order to relax displacing muscles or support 
weight of limb ; maintain coaptation by means of padding, and use 
claviculo-humeral bandage, adhesive plaster or Sayre's dressing, with per- 
haps gypsum reinforcement. 

Variation in site of fracture may cause some modification in details 
of this dressing. 



CHAPTER XVI 



FRACTURES OF THE HUMERUS 

Anatomy. — The humerus (Figs. 314 and 316) one of the typical long- 
bones of the skeleton, is composed of the upper extremity, the shaft, and 
the lower extremity. 

The upper extremity is composed of the head, which is directed in- 
ward, upward, and backward at an angle of 130 degrees with the axis of 



Greater tuberosity - 



Head 

Lesser tuberosity 



External bicipital or pectoral ridge 



Deltoid eminence 



External border 



External supracondylar ric 



Radial fossa 

External condyle 

Capitellum 



Bicipital groove 
Internal bicipital ridge 



Internal border 



Anterior border 



Internal supracondylar ridge 



Coronoid fossa 



Internal condyle 
Trochlea 



Fig. 314. — Right humerus, front view. 

the shaft, the anatomical neck, the greater and lesser tuberosities, and 
the surgical neck. The anatomical neck is the constricted portion imme- 
diately beneath the head, to which the capsular ligament is attached. 
Beneath the anatomical neck there are two rough prominences, the larger 
or greater tuberosity being directed outward and the smaller tuberosity 
being directed inward and forward ; between these two is the bicipital 
groove. It is this great tuberosity of the humerus which makes the 
point of the shoulder felt beneath the deltoid muscle on palpation of 
316 



FBACTUEES OF THE HUMEEUS 



317 



the normal joint. Below the tuberosities between the upper expanded 
end and the shaft there is a constriction of indefinite length, to which 
the name surgical neck is often applied. 

The shaft is cylindrical above and transversely expanded and triangu- 
lar below, and in the lower half of the shaft there are three surfaces, 
the antero-internal, the antero-external, and the posterior. 

The lower end of the humerus changes from the three-sided shape 
noted above to a flattened and broad form, and ends in the two condyles, 

•Supraspinatus 



Subscapularis 



Pectoralis major 
Latissimus dorsi 



Teres major 



Deltoid 



"oraco-brachialis 





Brachio-radialis 



Extensor carpi 
radialis long. 



Tendon common 
to exten. carp, 
rad. brev., ex- 
ten, communis 
digit orum, ex- 
ten, min. digiti, 
exten. carpi ul- 
naris 



>Brachialis anticus 



Pronator radii 
teres 

Tendon common 
to pronator ra- 
dii teres, flex, 
carpi radialis, 
palmaris lon- 
gus, flex, sub- 
lim. dig., flex. 
carpi ulnaris 

Pig. 315. — Right humerus, back view. 




Fig. 316. — Upper end of humerus, 

showing cupping of epiphysis to 

receive the pointed head of the 

diaphysis. (Piersol's Anatomy.) 



the internal and external, which are placed transversely in front at the 
lower end of the shaft. A continuation of the axis of the humerus would 
be at a point posterior to the condyles. This is shown by the lateral 
view of the lower end of the humerus and in part accounts for the 
extreme flexion and limited extension possible at the elbow- joint. The 
axis of the condyles is placed somewhat obliquely to that of the shaft, 
forming an angle of 85 degrees which accounts for the carrying" angle. 
The external surface of the external condyle forms a small blunt projec- 
tion, the external epicondyle, and on the inner surface of the internal 



318 



TREATISE OX FRACTURES 



condyle is placed the prominent internal epicondyle. Between the 
two condyles there are two anterior and one posterior depressions. 
The former are the coronoid fossa and the radial fossa for the 
accommodation of the coronoid process of the ulna and the head of 
the radius on full flexion; the latter or posterior depression, called the 
olecranon fossa, is for the olecranon process of the ulna on full extension. 
The articular surface of the lower end of the humerus consists of the 
capiteilum upon the external condyle, which articulates with the head of 
the radius; and the trochlea upon the internal condyle, which articulates 
with the sigmoid cavity of the ulna. These two articulating surfaces of 
the lower end of the humerus are divided by a ridge. 

Surface Markings. — The head of the humerus can be felt most readily 
The roundness of the shoulder is due to the bulk 



through the axilla 



Fig. 317a. 



Fig. 317b. 





Fig. 317a. — Rontgenogram of normal shoulder-joint 
Fig. 317ft. — Rontgenogram showing normal epiphysis of upper end of humerus. 

of the deltoid muscles overlying the greater and lesser tuberosities of the 
humerus, which may be felt through the muscle. Evidences of fracture 
of the upper end of the humerus may be determined by placing the ringers 
at the anterior edge of the deltoid ( deltopectoral groove) with the thumb 
behind, and then grasping the flexed elbow with the other hand (Fig. 
318a) ; by making careful rotation, crepitus may be determined in a 
non-impacted fracture. The shaft of the bone can be readily palpated 
throughout its entire length (Fig. 318/?)- The internal and external 
condyles of the humerus may be readily palpated (Fig. 319 ) ; and these 
two prominences may be used in conjunction with the tip of the olecranon 
in determining displacement of fragments in fractures at the lower end 
of the humerus or of the olecranon. In full extension a line drawn 
between the internal and external condyles posteriorly will touch the 
tip of the olecranon (Fig. 320). During full flexion the tip of the olec- 
ranon will be found below this line. 

The head of the radius may be palpated and felt to rotate in the 
dimple just below and anterior to the external condyle (Fig. 321). The 



FRACTURES OF THE HUMERUS 

Fig. 318a. Fig. 318&. 



319 




Fig. 318a. — Method of determining crepitus and abnormal mobility in fracture of the upper end of 

the humerus. 
Fig. 3186. — Method of determining crepitus and abnormal mobility in fracture of the shaft of the 

humerus. 



Fig. 319. 



Fig. 320. 




Fig. 319. — Method of palpation of the condyles of the humerus. 
Fig. 320. — Shows the normal relation of the olecranon process of the ulna and of the condyles of humerus. 

in full extension of the elbow. 



320 



TREATISE OX FRACTURES 



coronoid process may be felt in thin subjects by making deep pressure in 
the hollow, situated anteriorly just below the joint. The axis of the 
upper part of the upper extremity, or arm, forms with the fully extended 
and supinated forearm an obtuse angle, with its opening outwards, called 
the carrying angle (Fig. 322). This angle is greater in woman than in 
the man, in order to clear the wider female pelvis when the woman carries 
weights in her hand. 

Fractures of the Upper End of the Humerus 
Varieties of Fractures. — Fractures of the upper end of the humerus 
may be classified as : ( 1 ) fractures of the head ; (2 ) fractures of the ana- 
tomical neck; (3) fractures through the tuberosities ; (4) fractures (iso- 
lated) of the greater or lesser tube- 
rosity) ; (5) separation of the upper 
epiphysis; (6) fractures of the 




the Head of the 

323). — Fractures 



surgical neck. 

Fractures of 
Humerus (Fig. 

involving the head of the humerus 
without injury to other parts of the 
bone are extremely rare. Fractures 
involving the head are generally 
found in conjunction with frac- 
tures of the anatomical neck or 
tuberosities, or with anterior dislo- 
cation of the humerus. Fractures 
of the head may be fissured frac- 
tures. The fragments may be im- 
pacted or displaced, and can gen- 
erally only be detected by X-ray 
examination. They should be dif- 
ferentiated from fractures of the 
anatomical neck, subdeltoid bursitis, and sprain fractures. Cases have 
been recorded by Gosselin and Gross, and by Malgaigne. 

Etiology. — The articular surface may be chipped off, or may be in- 
dented, or the line of fracture may extend out through the anatomical or 
surgical neck, or the tuberosities. These fractures are occasionally seen 
accompanying dislocation. 

Symptoms. — Simple Assuring or even a complete separation of the 
head of the bone may be unrecognized. A radiogram should usually be 
made in injuries about the shoulder-joint. When the line of fracture 
extends into other parts, the symptoms present will partake of those seen 
in fractures of the various regions involved. Union is apt to occur with 
some deformity or excessive intra-articular callus and subsequent limi- 
tations of motion. 



Fig. 321. — Palpation of the head of the radius. 
Normally it may be felt to rotate with the shaft on 
pronation and supination of the hand. 



FRACTURES OF THE HUMERUS 



321 



Treatment. — Mere fissures or dents in 
the surface would seem to need no very 
vigorous treatment. Moderate support 
given to the shoulder by a bandage and 
only a little restriction of active move- 
ments of the joint are indicated. Traction 
by a weight hung below the flexed elbow 
might be required, if the fracture was at- 
tended with displacement when the patient 
was out of bed. When recumbent, the man 
could continue traction by means of a 
weight and pulley. Unless satisfactory 
reduction and approximation of the frag- 
ments can be obtained in fractures with 
displacement and shown to be so by 
radiogram, open operation for suture or 
excision of the head usually should be per- 
formed. It is possible that nailing the 
head in position, as is done in the femur, 
may give satisfactory results and thus 
obviate excision. In impacted fractures 
of the aged, operation may be unwise. 

Fractures of the Anatomical Neck. — 
These fractures occurring as isolated in- 
juries are almost as rare as fractures of 
the head of the bone, except in those in- 
stances in which they are associated with 
luxation of the humerus. The line of 
break must be within the capsule and separate the head not only from the 
shaft, but cut it off from the tuberosities to be a true cervical fracture. 

Etiology. — This fracture, although rare, occurs perhaps most fre- 
quently in advanced life and as a result of direct violence, such as a fall 
upon the shoulder. It may happen by indirect trauma, as in a fall upon 
the hand. The line of fracture is rarely limited to the anatomical neck, 
when it would be intracapsular, but extends into the adjacent bone, or it 
involves one or both tuberosities. It is frequently impacted. It is also 
occasionally seen in conjunction with luxation of the head. The upper 
fragment, when not impacted with the lower, may lie free in the cavity 
of the joint, or be in the axilla. The possibility of non-union in unim- 
pacted fractures of the anatomical neck should always be remembered, 
as well as the resulting intra-articular callus formation which may lead 
to a marked ossifying arthritis. 

Symptoms. — Fractures of the anatomical neck (Fig. 324) are often 
difficult to distinguish, without the aid of the radiogram, from fractures 
of the surgical neck, tuberosities, or intra-articular fractures of the 
21 




Fig. 322. — The carrying angle; formed by the 
deviation of the axis of the forearm from the 
humeral axis. (Davis' Applied Anatomy.) 



322 



TEEATISE OX FEACTUEES 



shoulder- joint. The chief symptoms are swelling, pain on motion, loss 
of function, and the gradual appearance of ecchymosis within forty-eight 
to seventy-two hours. Deformity as a rule is slight, unless the head is 
dislocated into the axilla. Crepitus may be demonstrated in non-impacted 
fractures, when the upper fragment remains in the joint cavity, but it is 
difficult to differentiate the crepitus from that obtained in other articular 
fractures near the shoulder- joint. There is generally slight flattening of 
the shoulder, shortening of the arm, if the upper fragment is dislocated, 
and marked pain on rotation of the arm. 

Diagnosis. — This can best be determined by the radiogram. In cases 
of injury about the shoulder-joint one should use this means of accurate 
diagnosis when possible. The condition should be differentiated from 





Fig. 323. 




Fig. 324. 












1 




, 














- 1,* -^ i ' ■*» 




'"*Sa^ 






^StMlh^ 










^ 






. 






■ 




> ' : * 






J 



Fig. 323. — Incomplete fracture of the head of the humerus. 

Fig. 324. — Fracture of the anatomical neck of the humerus, with dislocation of the head into the 

axilla. The semicircular group of arrows shows the position of the head. 



fracture of clavicle and of scapula, from luxation of the humerus, from 
fracture through its tuberosities, and from fracture of its surgical neck. 

Prognosis. — The prognosis is dependent upon the age of the patient, 
and upon whether the fragments are impacted. Complete recovery, 
except in impacted cases, is the exception. The usual result is recovery 
with moderate impairment of motion, chiefly in abduction. Necrosis of 
the head or non-union may occur, although union has taken place even in 
cases in which the head has been considerably isolated. 

Treatment. — The treatment of many of these cases is simple. When 
impaction of fragments is present the arm should be supported by a 
sling, the shoulder perhaps protected by a shoulder cap, and the arm held 
to the chest wall by means of a swathe. Very gentle massage and passive 
motion should be begun very early, not later perhaps than on the fifth to* 
the seventh day. When there is non-impaction with rotation outward of 
the head of the bone, attempts should be made to bring the line of fracture 
together by abduction and traction of the arm with synchronous pressure 



FRACTURES OF THE HUMERUS 



323 



upon the head. The limb should be held in this position either by a suitable 
traction or extension apparatus or by means of a triangular support. Gen- 
tle massage should be begun at the end of the first week. When the head 
has been dislocated into the axilla and in those instances in which union 
does not occur in non-impacted cases with the head remaining in the joint 
cavity, excision of the capital fragment usually should be performed. 
This procedure is advised only in those cases in which the patient's general 
health warrants such a procedure, When this is inadvisable, however, an 
unexpected degree of function may be observed even in the most un- 
promising cases. 

Fractures through the Tuberosities (Figs. 325 and 326). — These 
fractures are not as rare as fractures of the anatomical neck. Fracture of 



Fig. 325. 



Fig. 326. 




{/, 




Fig. 325. — Fracture of the humerus through the greater tuberosity, with dislocation of the head 

into the axilla. 
Fig. 326. — Fracture of the humerus through the tuberosities. 



the small tuberosity is less common than of the greater tuberosity. They 
are often found in conjunction with fracture lines extending partially 
through the anatomical neck and are at times hard to differentiate from 
high fractures of the surgical neck. The line of fracture is often seen to 
begin anteriorly about the level of the anatomical neck and to run down- 
ward and backward through the tuberosities. Comminuted fractures of 
the tuberosities are frequently seen. Such fractures are a common 
accompaniment of luxation of the head of the humerus. Displacement of 
the greater tuberosity is apt to be upward with either forward or back- 
ward tendency. There may be rotation of the fragments. The smaller 
tubercle when broken is apt to be displaced inwards. 

Etiology. — This fracture is the result of a fall directly upon the 
shoulder or upon the elbow when the arm is in a position of adduction 



324 TEEATISE OX FRACTURES 

with the elbow inward and backward. Fracture by abduction is very 
infrequent, and impaction of fragments is the rule. When one of the 
tuberosities alone is fractured without association with luxation of the 
humerus, the cause is usually muscular action. These avulsion fractures 
show moderate displacement and are not impacted fractures. 

Symptoms. — The symptoms of fracture through the tuberosities are 
swelling about the shoulder- joint, generally a moderate degree of shorten- 
ing due to impaction of the fragments, occasionally crepitus, inability to 
lift the arm, apparent thickening of the bone, and marked local tenderness 




Fig. 327. — Fracture of the greater tuberosity and of the surgical neck of the humerus. 

in the region of the tuberosities. A positive diagnosis can generally be 
made by the rontgenogram, and the differential diagnosis from fracture 
of the anatomical neck, the surgical neck, or an isolated fracture of either 
of the tuberosities established. The difficulty of taking two good X-ray 
plates in planes of an angle of 90 degrees in the shoulder region somewhat 
impairs the value of the radiographic diagnosis. An important result of 
a detached small tuberosity may be the dislocation of the long head of the 
biceps. The dragged-away tubercle destroys the inner edge of the bicipi- 
tal groove and may thus release the tendon, which slips inward. 

Treatment. — If impaction of the fragments is present and the head 
of the bone in its normal position, attempts at further reduction should 
not be made. The arm should be held to the side, the forearm placed in 
a sling and the shoulder protected by a shoulder cap for two weeks. The 



FRACTURES OF THE HUMERUS 



325 



value of the shoulder cap is not great as a fixation apparatus but protects 
the region from blows which might do harm. Fracture of the greater 
tubercle may require an abducted position of arm, if there be marked 
upward and outward rotation of the tubercle. A triangular rigid wire 
splint may be used to hold the arm from the chest or a gypsum encasement 
of chest and arm may be adopted. The avulsion fractures. Careful 
massage and passive motion should be employed early. The late results 
are generally a limitation in rotation and abduction. Where a dislocation 
of the head of the humerus accompanies the fracture, 
the head may be reduced by operative means and nailed 
to the shaft. If this is not feasible, resection of the 
head should be performed. 

Fractures (Isolated) of the Greater or Lesser 
Tuberosities. — Isolated fracture of the greater tuber- 
osity (Figs. 327 and 328) may or may not accompany 
anterior dislocation of the head of the humerus. One 
case has been reported by Malgaigne in which it ac- 
companied a backward dislocation of the head of 
the humerus. 

Statistics. — In Plagemann's statistics of 30 isolated 
fractures of the greater tuberosity, he differentiates 
three groups ; a tearing off of the greater tuberosity, a 
transverse or comminuted fracture of the tuberosity, 
and a tearing out of a small portion of its cortex. Of 
the first class the fracture was found six times in con- 
junction with a preglenoid dislocation, and eight times 
as an uncomplicated fracture ; of the second class, in 
four instances there was a transverse fracture of the 
upper face of the greater tuberosity, four times a mul- 
tiple transverse fracture, and three times a comminuted 
fracture of the entire tuberosity; and in the third class, 
in six instances there were portions of the cortex torn 
off the upper surface of the greater tuberosity. 

Fractures of the greater tuberosity were encoun- 
tered twenty-four times in the male and six times in 
the female. 

Etiology. — Fracture of the greater tuberosity is due either to a direct 
fall upon the shoulder, a fall upon the elbow or hand, pro- 
ducing at the time an accompanying dislocation of the head of the 
humerus, or to the direct pull of the attached supraspinatus, infra- 
spinatus, and teres minor muscles. The tuberosity may be entirely de- 
tached and dislocated upward and outward, or it may be incompletely 
detached and held by a portion of periosteum to the shaft. In the 
latter instance a longitudinal fissure is seen beginning at the level of the 
anatomical neck and running 4 downward. The fragment may be so 




Fig. 328. — Humerus, 
right; fracture of the 
greater tuberosity. The 
fracture has occurred 
with slight posterior 
displacement due to 
the action of the supra- 
spinatus, infraspinatus, 
and teres minor mus- 
cles. A deep fissure 
lies between the frag- 
ment and the head of 
the capsular ligament. 
Union is firm. (Mut- 
ter Museum, No. 
1262.30.) 




326 TEEATISE OX FRACTURES 

separated that the long tendons of the biceps may be interposed. When 
the fragment is entirely detached it may be displaced between the acro- 
mion and the head of the humerus, causing locking of the joint. Cases 
of fracture accompanying anterior dislocation of the humerus are 
often unrecognized. 

Symptoms. — Isolated fracture of the greater tuberosity with dislo- 
cation of the fragment may be recognized by the presence of crepitus when 
the arm is abducted and rotated. There is inability to rotate the arm 
outward, marked tenderness over the tuberosity, apparent increase in the 
anteroposterior diameter of the shoulder, and moderate projection of 
the acromion. When the fragment is not detached the only symptoms 
that may be present are localized tenderness, inability of outward rota- 
tion, and ecchymosis. When there 
is an accompanying dislocation of 
the head of the humerus, the pres- 
ence of fracture may be over- 
looked. Some authorities main- 
tain there is a marked liability to 
the recurrence of the dislocation 
of the head of the humerus when 
accompanied by fracture of the 
greater tuberosity. 

Diagnosis. — A diagnosis may 
be made from localized tenderness, 
failure of voluntary outward 
rotation, absence of shortening, 

Fig. 320.— Bony points to be noted in the region of the occasional Crepitus, absence of 

shoulder joint: (A) tip of acromion process; IB) great m <• 1 

tuberosity; (C) bicipital groove; (D) coracoid process; flattening 1 OT the shoulder, and 
(E) lesser tuberosity. ° 

the retention of rotation of the 
head of the bone with the shaft. Confirmation by radiologic study may 
be essential. 

Treatment.— Where the fragment remains in its normal position 
due to the attached periosteum, the only dressing required will be a 
wrist-sling, a swathe fixing the arm to the chest and wall, and a protective 
shoulder cap. When the tuberosity is displaced upward and outward, 
the arm should be fixed in a position of abduction and outward rotation. 
When the displaced fragment tends to interpose between the acromion 
and the head of the humerus, the fragment should be exposed and nailed 
in its proper place as suggested and performed by Keen. 

Isolated fractures of the lesser tuberosity are more infrequent than 
those of the greater tuberosity. They have been observed accompanying 
an anterior dislocation of the head of the humerus, a fracture of the 
greater tuberosity, or a fracture of the anatomical neck. When seen 
unaccompanied by other lesion, the fracture is generally due to forcible 
outward rotation of the arm or to sudden contraction of the subscapu- 




A . 






• — 


.'.'.£>'■' 


B 

c.l 




• • 


W— 


....E 



FRACTURES OF THE HUMERUS 



327 



laris muscle. When separation of the tuberosity takes place, the inner 
edge of the occipital groove is removed, and dislocation of the long 
tendon of the biceps muscle may occur. 

Symptoms. — Inward rotation of the humerus is impossible. Out- 
ward rotation is increased. There is generally marked tenderness below 
the coraeoid process and a firm mass not moving with rotation of the 
arm, felt in the position of the small tubercle. Bardenheuer states that 
the arm tends to assume a position of outward rotation. Crepitus may 
at times be felt on forcible inward rotation of the humerus. 

Diagnosis.— This can be made by the inability of voluntary inward 
rotation of the arm, the presence of tenderness, and the detection of a 




FlG. 330. — Ossification of humerus. (A) just before birth; (B) in the first year; (C) at three years; (CO 
sections of ends of preceding; (£>) at five years; (E) at about thirteen years; (£') sections of ends of pre- 
ceding; (F) at about sixteen; (F') sections of ends of preceding, (a) Center for shaft; (b) for head; (c) for 
capitellum and part of trochlea; (d) for greater tuberosity; (e) for head and tuberosities in transverse section; 
(/) for internal condyle; (g) for inner part of trochlea. (Piersol.) 



firm mass and occasional crepitus just outside and below the coraeoid 
process. A radiogram will settle the diagnosis. 

Treatment. — This consists in flexion of the forearm upon the arm 
to relax the biceps muscle, adduction, and inward rotation. This posture 
is maintained by a wrist-sling, a swathe binding the arm to the chest wall, 
and a protective shoulder cap. Fixation should be continued for four 
weeks, and judicious massage and gentle passive motion begun at the end 
of ten days. The late results are good. 

Separation of the Upper Epiphysis. — The shape and limits of the 
upper epiphysis of the humerus may readily be seen by the accompanying 
radiograms (Figs. 316 and 317&). The upper epiphysis is formed of 
the head and the two tuberosities. The line of the epiphyseal cartilage 
in its inner third is the same as that of the anatomical neck, and the 
remaining portion passes outward just below the tuberosities. The 
under surface of the epiphysis is cup-shaped, deeper in its centre than 
at its periphery. 



328 



TREATISE OX FRACTURES 



Epiphy 
in fancy to 
tween the 

separation 
number of 
a fracture 
diaphysis. 



seal separations (Figs. 331 and 332) have been observed from 
the twentieth year of life. They occur most frequently be- 
age of eight and eighteen. In many cases there is only a 
at the line of the epiphyseal cartilage, but in a considerable 
cases, in addition to the separation of the epiphysis, there is 
cutting off a wedge-shaped portion of the upper end of the 
This remains attached to the epiphysis. One should remem- 



Fig. 331. 



Fig. 332. 





?* 



ctCRaU-S majo,^ 



/f-- ^ 



'/*; 



L 




Fig. 331. — Drawing to show the usual character of epiphyseal separation. A portion of the diaphysis is 

usually attached to the separated epiphysis. | Made after rontgenograms of Fig. 332.) 
Fig. 332. — Separation of upper epiphysis of humerus. Note that a small portion of the edge of the dia- 
physis is attached to the epiphyses. (See Fig. 331.) 

ber that only after the third year is it possible to distinguish the entire 
epiphysis by radiogram on account of the three centres of ossification 
appearing at this time. The humerus is usually developed from seven 
ossific centres : one for the shaft, one for the head, one for the tuberosities, 
one for the radial head, one for the trochlear surface of the lower articular 
surface, and one for each condyle. Nearly the whole length of the shaft 
is developed by the time of birth, but the ends are at that date still carti- 
laginous. At the fifth year the centres for head and tuberosities are 
united to each other forming a single large epiphysis. This epiphysis 



FRACTURES OF THE HUMERUS 



329 



unites with the shaft at about the twentieth year. It is said that some- 
times the smaller tuberosity has a special ossific centre. 

Etiology. — Separations of the upper epiphysis of the humerus have 
been observed in infants after childbirth due to traction upon the arm, 
to inward pressure upon the outer surface of the humerus, or to injury 
from the finger of the obstetrician hooked into the axilla. The epiphysis 
at this time is of course still cartilaginous. The injury after ossification 



Fig. 333a. 



Fig. 333b. 



y 



ijc 




Fig. 333a- — Separation of upper epiphysis of humerus. Note that line of fracture begins at the 
epiphyseal line and that an unusually large fragment of the diaphysis is attached to the epiphyses. 

(Before reduction.) 
Fig. 3336. — Same as Fig. 333a, after reduction. 



is the result of direct violence, as a fall directly upon the shoulder, or of 
indirect violence, as by hyperabduction of the arm, or by forcible outward 
rotation combined with traction. The condition may also be the result 
of a fall upon the elbow when the arm is in abduction. 

Symptoms. — In many cases there may be no gross deformity to the 
shoulder region aside from a general swelling. If the separation takes 
place with a fracture of a portion of the upper end of the diaphysis, as is 
seen in young children, the head of the bone may be rotated by the 
attached muscles so that the articular surface is directed downward and 



330 TEEATISE OX FBACTUKES 

the fractured surface upward. The upper end of the diaphysis may 
assume an outward position, it may be found posterior, anterior, or dis- 
located into the axilla, and its end may be felt in any of these positions. 
The anterior dislocation of the upper end of the shaft is a very common 
form of deformity (Figs. 3330-335). When the end is displaced into 
the axilla, it may be below the coracoid process and readily detected. 
Crepitus is generally soft in character unless a fracture of a portion of 
the diaphysis is also present, in which instance true bony crepitus may 
be elicited in the absence of impaction of fragments. Pain, disability, 



Fig. 334a- FlG - 334&- 




V 




I 




Pigs. 334<* and 334b. — Photographs of case (Figs. 333a and 333b) of separation of upper epiphysis of left 

humerus. Fig. 334a shows upper end of diaphysis is displaced forward, producing the swelling observed 

at the anterior aspect of the left shoulder. Fig. 334b, normal right shoulder for comparison. 

and ecchymosis appearing in the course of several days are characteristic 
symptoms. Passive rotation of the elbow discloses absence of rotation 
of the head of the bone in non-impacted fractures ; when the latter con- 
dition is present rotation of the head occurs. In some cases there may 
be considerable stripping up of the periosteum, which remains attached 
to the two fragments and prevents reduction. 

Diagnosis. — In making a correct diagnosis of this lesion the radio- 
gram is often invaluable. At other times it may be of little use. It 
should be used. Before the third year of life the radiogram will be of 
little value and the diagnosis will depend greatly upon the deformity 
that may be present, localized pain, and an inability of voluntary move- 
ments. After this time of life it is of value in recognizing separations 



FRACTURES OF THE HUMERUS 



331 



that have not been perfectly reduced, and in those in which there is a 
fracture of the diaphysis with the adherence of a small fragment of 
bone to the epiphysis. In some patients examined a considerable time 
after injury, it is possible to diagnose a previous epiphyseal separation 
by the radiogram showing new bone formation. A careful comparison 
with the radiogram of the sound shoulder is frequently essential, and 
very often radiograms taken in several planes will be necessary. Other 
signs by which a diagnosis may be made are visible projection of the 
upper end of the diaphysis, change in the normal axis of the humerus, 
and occasional shortening and distortion of the anterior axillary fold. 
It is liable then to be mistaken for dislocation of the head of the humerus. 
Treatment.— In uncomplicated cases without displacement of frag- 




FiG- 335- — Photograph taken ten weeks after injury; all motions ofthe arm and shoulder are normal 
excepting abduction, which is still slightly impaired. 

ments and in those in which reduction may readily be accomplished by 
means of traction, hyperabduction and manipulation, retention is best 
maintained by placing a small folded towel in the axilla, and fixing the 
arm to the chest wall by a modified Velpeau dressing. When reduction 
is difficult, a general anaesthetic, preferably nitrous oxide gas, should 
be used ; then by forced traction, hyperabduction and manipulation, reduc- 
tion may usually be accomplished. The arm is to> be dressed with the 
modified Velpeau bandage. If a secondary radiogram shows partial recur- 
rence of the deformity, the arm should be placed in a position of perma- 
nent abduction and held there by a Monks splint or a gypsum encasement 
or by permanent traction with weight and pulley. In the last method the 
patient is kept in bed for fifteen or twenty days. When reduction cannot 
be accomplished, owing to rotation of the epiphysis or to the presence 
of a portion of attached periosteum preventing replacement, incision 



332 TREATISE OX FRACTURES 

and subsequent reduction should be adopted. The line of separation 
should be exposed, the fragments reduced and coaptation maintained by 
chromic catgut or fine, flexible wire sutures passed through the perios- 
teum. One should avoid doing too much injury to the epiphyseal carti- 
lage by the insertion of sutures, nails or screws through it. Serial 
radiograms should be made after reduction to ascertain whether reduction 
is being maintained. Reduction without any internal fixation may be all 
that is needed when the bone has been exposed and replacement accom- 
plished under the surgeon's eyes. 

After-results. — Interference with the subsequent growth of the 
humerus from the upper end is always a possibility in diastases of 
epiphyses. In giving a prognosis this liability should always be remem- 
bered. After union takes place there will generally be some temporary 

Fig. 336. Fig. 337. 




Fig. 336. — Oblique fracture of surgical neck of left humerus. 
Fig. 337. — Comminuted fracture of surgical neck of right humerus. 

reduction of abduction and rotation, which should disappear within three 
to four months. 

Fractures of the Surgical Neck (Figs. 336—338). — In this group of 
fractures are included those occurring between the epiphyseal line and 
the attachment of the greater pectoral muscle. The level of the fracture 
line is subject to considerable variation; it may extend upward into the 
head of the bone as seen in comminuted fractures, or it may descend to a 
lower level than the upper edge of the attached pectoral muscle, as in 
oblique fractures. The line of fracture may be transverse, oblique, spiral, 
or comminuted in character. The fragments may be impacted or non- 
impacted. In Plagemann's 22 cases the lines of fracture were : transverse 
in 10 instances, oblique in 3, spiral in 2, and in 7 cases there was a bending 
fracture with the breaking off of a three-cornered piece from the cortex 
of the humerus. The spiral fractures were found especally in the young, 
the oblique and bending fractures in strong men. while the transverse- 
fractures were observed at all ages. Fractures in this area are con- 
sidered by many authorities to occur in the adult as a result of such 



FRACTURES OF THE HUMERUS 



33: 



violence as in children produces an epiphyseal separation. While this 
may be partially so, attention is directed to the many fractures of the 
surgical neck occurring during childhood, and in which there is no lesion 
of the epiphyseal cartilage. Comminution and associated fractures of the 
tuberosities are frequently seen. 

Etiology. — The fracture may result from falls upon the lateral or 



Fig. 338. 



Fig. 339. 





Fig. 338. — Humerus, left; fracture of the surgical neck; union. The fracture passed im- 
mediately below the condyles and through the lower portion of the anatomical neck. The 
lower fragment was drawn to the inner side and has united in a position of outward 
rotation; an irregular opening leads through the callus in the anterior surface to the head. 

The union is firm. (Mutter Museum, No. 1262.15.) 
Fig. 339. — Method of determining shortening in fracture of the humerus by measuring 
from the acromion process of the scapula to the external condyle of the humerus, and 

comparison with the same measurement of the other arm. 

anterior aspect of the shoulder, from a blow directed downward upon 
the upper arm when the latter is in a position of abduction, from hyper- 
abduction with leverage against the acromion process, by falls upon the 
hand or elbow, and rarely by muscular action. 

Symptoms. — In fractures of this variety there are localized pain, ten- 
derness, complete or almost complete inability to use the arm, swelling, 
and effusion of blood in the tissues. In impacted fracture there is gener- 



134 



TREATISE OX FRACTURES 



ally some thickening of the bone at the seat of fracture, clue in many 
cases to comminution of fragments, and flattening of the shoulder exter- 
nally ; the arm is held supported by the other hand, and is generally kept 
close to the side. There may be moderate deformity at the seat of fracture 
due to slight displacement of the upper end of the lower fragment inward, 
and slight internal angulation. The shortening is generally slight and is 
dependent upon the degree of impaction. Rotation of the elbow shows 
coincident rotation of the head of the humerus. In non-impacted frac- 



FlG. 340. 



Fig. 341. 









Fig. 340. — Fracture of humerus through surgical neck. The line of fracture is irregularly transverse 

and low. 
Fig. 341. — Drawing to show the displacement of fragments in Fig. 340, and the muscles which deter- 
mine the character of the displacement. 



tures in addition to the local signs of fracture there is often marked 
shortening (Fig. 339), as measured from the tip of the acromion process 
to the external condyle, and the head of the bone fails to rotate with, 
rotation of the shaft and elbow. The deformity may be slight or exten- 
sive. When this is present the upper fragment is generally abducted 
and rotated outward, due to the pull of the muscles attached to the tube- 
rosities, or it may be rotated inward and displaced upward and forward; 
while the upper end of the lower fragment is drawn inward, upward, and 
forward by the pull of the pectoralis major, teres major, and latissimus 
dorsi muscles (Figs. 340 and 341). The upper end of the lower frag- 
ment may, however, be displaced upward and outward by the pull of 
the deltoid muscle in those cases of oblique fracture in which the line 



FBACTUEES OF THE HUMERUS 335 

of fracture is from without, running inward, and downward. Abduction 
of the elbow is constant as a rule, and in some cases may resemble the 
position assumed in interior dislocations of the head of the humerus. 
Crepitus is generally obtainable in all cases of non-impacted fractures 
after reduction has been accomplished, and in most cases before reduction 
has been attempted. In all non-impacted fractures there is a marked 
depression at the insertion of the deltoid muscle. The exact line of 
fracture and the dislocation of the fragments may readily be determined 
by radiograms. 

Diagnosis. — In an ordinary case, the recognition of fracture of the 
surgical neck is generally made without difficulty. In impacted fractures 
the diagnosis will be determined by the presence of localized pain, swell- 
ing and thickening about the site of the suspected fracture, ecchymosis, 
inability to use the arm, and the presence of moderate deformity ; confirma- 
tion may be made with radiograms. In non-impacted fractures the diag- 
nosis will be made from localized signs of fracture, crepitus, abnormal 
mobility, characteristic deformity, shortening, and the failure of the 
head of the bone to rotate with rotation of the elbow and shaft, although 
its position is evidently not changed from normal. The radiogram of 
course acts as contributory evidence of a fracture. Fracture of the 
surgical neck may be differentiated from dislocation of the head of the 
humerus by the presence of the head of the bone in the glenoid cavity, 
by crepitus, and the other characteristic signs of fracture ; and the absence 
of the symptoms peculiar to luxations at the shoulder- joints. High frac- 
tures of the surgical neck are often mistaken for fractures of the ana- 
tomical neck. 

Complications. — These are injury to the axillary vessels or the 
brachial plexus, empalement of the muscles and at times the skin by 
sharp fragments, and rupture of the tendon of the biceps muscle. These 
complications are rare. 

Diagnosis of Injuries About the Shoulder- joint. — Investigation of in- 
juries in the vicinity of the shoulder derives much of its importance from 
the necessary difference in treatment of luxations and fractures. Recog- 
nition that a fracture and not a dislocation exists is of more importance 
than a knowledge of the exact situation of the line of fracture. The latter 
information may be obtained later by fluoroscopic or radiographic study. 

The relation of the bony prominences to one another should be studied 
and any variations from the normal be established by comparison with 
the unhurt shoulder. The head of the humerus should be grasped with 
the fingers of one hand while the examiner's other hand rotates the upper 
arm after taking hold of the bent elbow. If a fracture exists between 
these two points, the motion given the lower end of the humerus will not 
be transmitted to the head unless the fracture is impacted. The same 
manipulation will usually in cases of fracture develop crepitus, especially 
if some traction be used at the time to draw overlapping ends into contact. 



336 TEEATISE OX FRACTURES 

When the head of the humerus is in normal position the upper part 
of a straight rod laid upon the outside of the arm from shoulder to elbow 
will be from a half inch to over an inch from the edge of the acromion; 
but if the head is not in the glenoid cavity the rod will touch the acromion 
unless very great swelling of the soft parts be present. 

In the usual dislocations of the head of the humerus the shoulder 
will be found flattened, the acromion very prominent with a depression 
below it, into which one's finger-tips may be pressed, the elbow will be 
abducted from the chest, the arm rotated inward. The head of the 
humerus will be felt in its abnormal situation under the coracoid process 
in the axilla or below the clavicle. In addition to these symptoms volun- 
tary motion is lost : passive motion greatly restricted ; it is impossible to 
place the patient's hand on the opposite shoulder while the elbow of the 
injured side is pressed close to the chest; the long axis of the humerus is 
not directed toward the glenoid cavity but internally to it, where the head 
of the bone is felt to move when the elbow is rotated ; no true fracture 
crepitus is developed, though a soft rubbing sensation may be detected; 
and after reduction the deformity does not recur on removing restraint 
from the limb. 

Fracture of the neck of the scapula is known from the anterior dis- 
locations of the humerus by absence of rigidity during passive movements, 
which are almost unlimited : by crepitation, and by immediate recurrence 
of deformity when pressure, which has pushed up the arm, is withdrawn. 

Fractures of the head and of the anatomical neck of the humerus are 
infrequent and obscure of diagnosis, so are fractures through the tubercles, 
and of either tubercle alone. These injuries are not likely to occur 
except in connection with luxations of the head of the bone. Their 
differential diagnosis can hardly be made without resort to radiologi- 
cal study. 

Epiphyseal separation occurs before the twentieth year of age, gives 
palpable evidence of the head of the humerus in its normal site, but not 
moving when the arm is rotated, and allows the upper end of the humeral 
shaft to be felt in front of, or to the inner side of, the head. Soft crepi- 
tation is developed when the separated surfaces are placed in apposition 
and moved against each other : the elbow may readily be pressed close 
to the ribs, although the arm is directed somewhat outward and back- 
ward ; voluntary motion is lost, and passive mobility increased. 

Fracture of the surgical neck of the arm bone is the common lesion 
in the shoulder region when it is subjected to severe strain, and is there- 
fore most frequently to be differentiated from luxation of the shoulder- 
joint. The deformity is like that found in epiphyseal diastasis except 
when impaction of fragments has taken place at the time of injury. 
Then there is little deformity, no crepitus and no preternatural mobility. 
Otherwise these characteristics of fracture are observable. They are 
unlike the symptoms of dislocation except that in all three of these inju- 



FRACTURES OF THE HUMERUS 



337 



ries there is loss of voluntary movement. In dislocation this loss is due 
to entanglement of the humeral head in its abnormal position away from 
the glenoid socket and outside of the torn ligamentous capsule. This 
gives an appearance of rigidity to the arm and prevents voluntary motion. 
In fracture and diastasis the loss of active motion results from destruction 
of the lever through which the muscles act. This gives an appearance 
of helpless inactivity. In doubtful cases, and indeed whenever confirma- 
tion is necessary or desirable, the resort to fluoroscopic or skiagraphic 
evidence is to be prompt. 

Any of these fractures at the tipper end of the humerus may be com- 
plicated with dislocation of the shoulder- joint. The symptoms of the 
double lesion will be a flat shoulder, prominent acromion, and abnormal 
location of the globe-like humeral 
head, abnormal mobility, crepitus 
and deformity in the axis of the 
shaft of the humerus. The free- 
dom of passive motion and the ease 
with which the hand can be placed 
on the opposite shoulder while the 
elbow is pressed to the ribs will 
serve to differentiate the injury 
from uncomplicated dislocation. If 
the fracture is a mere detachment 
of the greater tubercle the last two 
symptoms will not be present. 

Sprain or contusion of the joint 
or damage to the soft tissues alone 
may be assumed when none of the 
lesions just discussed can be discov- 
ered ; provided that fracture of the clavicle, dislocation of the outer end of 
the clavicle, fracture and diastasis of the acromial and coracoid processes 
of the scapula have been eliminated. It also must not be forgotten that 
rupture of the long tendon of the biceps muscle or dislocation of this struc- 
ture from the bicipital groove in the humerus is a possible lesion of the 
musculature of this shoulder region. 

Treatment. — The treatment of fractures of the surgical neck of the 
humerus is dependent in a great measure upon the occurrence or non- 
occurrence of impaction of fragments. 

In impaction of fragments, in which the radiogram shows little dis- 
placement and slight malalignment, the best results will be obtained 
probably by avoiding separation of fragments and using a wrist-sling, a 
small axillary pad, a circular swathe binding the arm to the chest, and a 
protective shoulder cap. Gentle massage and passive motion should be 
begun at the end of the third or the fourth day and immobilization con- 
tinued for three to four weeks. 
22 




342. — Method of reduction of fragments in 
fracture of the surgical neck of the humerus by 
traction and manipulation. 



338 



TEEATISE OX FBACTURES 



In non-impacted fractures the line of procedure and form of treat- 
ment are entirely different. The best results are obtained by complete 
reduction and apposition of the fractured ends. In many instances this 
can be accomplished by traction and manipulation alone (Fig. 342) dur- 
ing thorough muscular relaxation obtained under general anaesthesia. 
After reduction three forms of retention are favorable. In the transverse 
fractures, reduction is not as a rule followed by recurrence of deformity 
if proper retentive apparatus is applied. It is desirable to use an axillary 
pad to control the inward pull of the greater pectoral and broad dorsal 
muscles, to employ a wrist-sling, to fix the arm to the chest wall with a 
swathe, and perhaps to protect the region with a shoulder-cap splint 



Fig. 343. 



Fig. 344- 





Fig. 343. — Dressing for fracture of the surgical neck of the humerus. After reduction of the fragments, 
the arm should be kept away from the chest wall by a moderately thick pad, the forearm supported by 
a wrist-sling, and the shoulder region protected by a shoulder cap. 
Fig. 344. — Shows completed dressing for fracture of the surgical neck of the humerus. 



(Figs. 343 and 344). The last is often unnecessary and sometimes unde- 
sirable. The cases in which this dressing will not prevent recurrence of 
deformity are as a rule the oblique, spiral, and multiple fractures. For 
these, ambulatory treatment with the use of vertical traction is sometimes 
sufficient, but may be inefficient because it is seldom constant. A con- 
siderable number of these cases are best treated by recumbency in bed and 
the application of continuous traction apparatus in the abducted position. 
There are, however, a small number of these fractures in which, for 
various reasons, ideal results cannot be obtained by these methods. In 
these it is wise to adopt open operation and obtain anatomical approxi- 
mation and fixation by means of suture of kangaroo tendon, chromicized 
catgut or wire, nailing, bone dowel or graft inlay, or by a metal plate or 
Parham band. Additional external support is then given outside the sur- 
face of the arm, forearm and hand by suitable dressings. In some cases 



FRACTURES OF THE HUMERUS 



339 



operation exposing the seat of fracture will permit reduction with such 
perfect coaptation under the eyes of the surgeon that the direct fixation 
methods mentioned will not be necessary. External splints or plastic 
encasements are then used. The ideal incision is made along the anterior 
border of the deltoid muscle. 

Many fractures at the upper end of the humerus may be satisfactorily 
treated by simple restraint of motion induced by carrying a broad strip 
of adhesive plaster or bandage once around the arm and chest and 
placing the wrist in a, narrow sling. The elbow should not be supported 
because its weight gives a little traction on the lower fragment. A sling 
holding the elbow may make pressure upward. The knotted sling may be 
applied after about two weeks (Fig. 345) in such cases, if there is little 
tendency to displacement and the patient is cautious not to put strain on the 
bone. Light stroking massage may be started im- 
mediately and passive motion begun at the end of 
a week. Recent experience has shown that early 
mobilization, passive and active, is better for frac- 
tures near or actually involving joints than long 
confinement. Lucas-Championniere in France and 
Mennell and Bennett in Great Britain have for years 
laid stress on the value of such management of 
fractures in general. The retentive dressing is 
needed for about four weeks ; the sling should be 
used for three weeks longer. 

If a free elbow does not give sufficient traction 
to correct overriding, a weight may be attached to 
the arm by adhesive plaster while the patient is 
walking and pulley and weight traction used when 
he is in bed at night. Other fractures in this region 
may need in addition the hollow of the axilla filled 
with a folded napkin or thin compress and the arm 
secured against the chest with the elbow carried a little forward. The 
axillary pad will sometimes give better support to the broken shaft, if 
made thicker at its lower end. By these dressings the thorax acts as a 
splint. In such cases the shoulder cap of gypsum or other rigid material 
is usually unnecessary. When the fracture is at the lower part of the 
surgical neck, treatment like that for shaft fractures is usually efficient. 

Fractures with external rotation of the upper fragment may require 
the shaft fragment to be strongly abducted in order to obtain proper 
coaptation and prevent angular or rotatory deformity. This is readily 
obtained by putting the patient in bed and employing traction and counter- 
traction. Elevating the side of the bed gives countertraction from the 
patient's own weight ; and traction in the requisite direction is gained by 
means of adhesive plaster, rope, pulley, and weights. The pulley is fast- 
ened to any firm object near the bed. The lower fragment is thus brought 




Fig. 345. — The knotted sling. 



34:0 



TEEATISE OX FBACTUKES 



in contact with the upper fragment. Verification of the accuracy of the 
apposition is possible by bedside X-ray plates or fluoroscopic examination. 
More complicated devices such as the Balkan frame and others may be 
employed. The arm may be abducted to any degree in the horizontal 
plane, even carried to a right angle with the middle line of the body, or it 
may be maintained in a vertical posture as the patient lies on his back. 
Heavy wire splints may be made similar in action to the Thomas traction 
splint for the lower extremity. 

After-results. — These are generally good. Impairment of full motion 
persists for a time, but is often overcome by hot-water soaking, persistent 

massage, and passive and active motions. Pas- 
sive motions or massage that cause pain are to 
be avoided. They are the relics of unwise sur- 
gical treatment. In some cases there will be 
permanent impairment of motion due to exu- 
berant callus, to failure properly to reduce and 
maintain reduction, to comminution of frag- 
ments, and to involvement of muscles in project- 
ing sharp fragments. Pseudarthrosis is infre- 
quent, and delayed union when seen is not 
generally permanent. 

Fractures of the Shaft of the Humerus 

Varieties of Fractures (Figs. 347-351"). — 
Fractures of the shaft of the humerus include 
all fractures involving the diaphysis between the 
insertion of the pectoralis major muscle and the 
upper limits of the supracondylar ridges. These 
fractures are as a rule complete and closed in 
character. Occasionally an incomplete fracture 
of the shaft is observed in children. Plagemann, in the 18 cases of his 
statistics, gives the lines of fracture as follows: 11 transverse, 2 oblique, 
3 spiral, and 2 bending fractures with the separation of a rhomboidal piece 
of bone. Longitudinal fractures are extremely rare, but have been re- 
ported by Gurlt, Cloquet, and Kronlein. 

Etiology. — Fractures of the shaft are the result of external violence 
or muscular action. Fractures by external violence result from a direct 
blow, a fall upon the arm against some object, by crushing accidents, 
and collision of vehicles. Fractures in these regions by indirect violence 
such as a fall upon the elbow or hand are extremely rare. Fractures by 
muscular action are more frequent in the shaft of the humerus than in 
any other bone. They result from the throwing of objects, the use of 
racquets, in tests of strength, and in wrestling. Pathologic fractures are 
not infrequent in the shaft of the humerus, and occur from malignant 




Fig. 346. — Weight traction for 

fractures in upper portion of 

humerus (Pye). 



FRACTURES OF THE HUMERUS 

Fig. 347. Fig. 348. 



341 




©f 





Fig. 349. 



Fig. 350. 



Fig. 347. — Spiral fracture of shaft of humerus. 
Fig. 348. — Irregular transverse fracture of the shaft of the humerus. Reduction and 
immobilization have been faulty, so that union has occurred with marked deformity, 
angularity, and overriding. Note the extensive callus which has been produced, not only 
at the seat of fracture, but also for a long distance away, due to the stripping up of the 

periosteum. 

Fig. 349. — Transverse fracture of middle of shaft of humerus. 

FlG. 350. — Oblique fracture of shaft of humerus with overriding and angular deformity. 



342 



TREATISE OX FRACTURES 



or other disease of the bone, and in nervous affections, particularly in 
tabes dorsalis and syringomyelia. 

Symptoms. — The symptoms of fractures of the shaft are those com- 
mon to all fractures, such as loss of function, pain, tenderness, crepitus, 
abnormal mobility, and deformity. The last is dependent upon the site 
of fracture, the fracturing force, and the pull of muscles. In fractures 
of the upper third the lower end of the upper fragment is drawn inward 

by the pectoralis major, latissi- 
mus dorsi, and teres major mus- 
cles, and the upper end of the 
lower fragment pulled upward by 
the deltoid, and in some degree by 
the biceps and triceps muscles 
(Figs. 352a and 352^). In frac- 
tures of the middle third there 
may be slight overlapping of the 
fragments ; generally it is absent. 
In fractures at the junction of 
the middle and lower thirds the 
upper fragment is not displaced 
to any appreciable extent, but 
the lower fragment is apt to be 
drawn upward and backward by 
the triceps muscle. 

Diagnosis. — This may readily 
be made by the usual evidence 
of fracture and radiograms. Lit- 
tle difficulty is experienced in 
making a diagnosis. 

Complications. — The compli- 
cations of fracture of the shaft 
are injury to the blood-vessels or 
to the nerves, and pyogenic infec- 
tion in open fractures. Injury to 
the blood-vessels may be the re- 
sult of the fracturing force or 
may be due to puncture or laceration of the brachial artery and its 
accompanying veins from sharp fragments of bone, and is shown by great 
swelling of the arm and interference with the brachial or radial pulse ; and 
later by the development of thrombosis and gangrene. Injury to the 
nerves may consist in laceration from sharp fragments, inclusion of a 
nerve in callus, or the result of overstretching. The nerve most fre- 
quently injured is the musculospiral, although the median and ulnar nerves 
may also suffer injury. Von Bruns reports 189 injuries of nerves com- 
plicating fractures; and of these 138 were of the upper extremity. The 




Fig. 351. — Long oblique fracture of shaft of humerus. 



FRACTURES OF THE HUMERUS 



343 



musculospiral was involved in yj cases, the ulnar in 19, and the median in 
17. In 52 per cent.^pf cases of injury to the musculospiral nerve the 
fracture was in the middle third, and in 38 per cent, in the lower third. 
Blenke, in a report of 68 cases of musculospiral paralysis found that the 
fracture was in the middle third in 56.3 per cent, and in the lower third 
in 41.3 per cent. 

Three forms of musculospiral paralysis are recognized : Primary 
paralysis is due to the nerve injury caused either by the fracturing force, 



Fig. 352a. 




Fig. 352a. — Transverse fracture of the shaft of the humerus. (See Fig. 352ft. ) 
Fig. 3526. — Drawing made from Fig. 352a to demonstrate the action of the muscles which determine 
to a great extent the character of the displacement of the fragments in fracture below the attachment 

of the pectoralis major muscle. 

by the sharp ends of fragments, or by being caught between fragments 
and crushed. Even with apparent continuity of nerve structure the nerve- 
fibres may be destroyed within the neurilemma. Intermediate paralysis 
(Figs. 353 and 354) is due to the stretching of the nerve over dislocated 
fragments and may appear within a few hours or it may not appear for 
several days. Secondary paralysis does not appear until the end of three 
to four weeks and is due to pressure from surrounding or lateral callus 
or to pressure from cicatricial tissue. The symptoms of nerve injury may 
appear immediately or later, and are shown by motor paralysis and loss of 
sensation over the region supplied by the nerve. The most common symp- 



3U 



TEEATISE OX FKACTUKES 



toms of injury to the musculospiral nerve is wrist-drop. When the nerve 
is only irritated hyperesthesia is present. 

In the slight forms of paralysis due to compression it is often the 
rule that recovery takes place within a few months without any treatment 
being applied to the nerve itself. In such cases support of the forearm 
and hand, combined with massage, passive motion, and electricity, will be 
followed by restoration to the normal condition. 

When severe injury to the nerve 
has occurred and the reactions of 
degeneration are present, or in 
those instances in which secondary 
" wrist-drop " has occurred as a re- 
sult of the presence of callus, opera- 
tive means of restoration of nerve 
continuity or release from callus 
will be necessary. If operative dis- 
section shows the nerve is torn 
completely across, attempts should 
be made to suture the severed ends 
by direct apposition or by plastic 
neurorrhaphy ; if this is impossible 
on account of great loss of nerve 
tissue, the intervening gap may be 
filled by a graft from the radial 
nerve, or the ends of the severed 
nerve may be implanted into the 
median nerve. A graft might be 
furnished by the patient's sciatic 
nerve, which is so large as scarcely 
to miss the small strip required. 

When the paralysis is the result 
of ensheathing callus, this should be 
chiselled away and the nerve simply 
released, or given a new bed in mus- 
cular tissue, or severed by a fascial 
graft. Such procedures may be 
expected to give complete restoration of function after a sufficient time 
has elapsed. When the paralysis proves to be permanent, the disability 
may be improved by tendon grafting of the muscles in the affected region. 
Treatment. — All fractures of the shaft of the humerus should first 
be carefully examined for evidence of injury to blood-vessels and nerves. 
If these complications do not exist, reduction and immobilization of the 
fragments should be performed. Fractures of the shaft should be thor- 
oughly reduced, under general anaesthesia, if there is doubt as to the re- 
placement and no contra-indication exists to using nitrous oxide or ether. 




Fig. 353. — Rontgenogram of oblique fracture of 
the shaft of the humerus in the region of the mus- 
culospiral nerve ; followed by paralysis of the muscles 
supplied b3^ this nerve. 



FRACTURES OF THE HUMERUS 



345 



Transverse fractures as a rule remain in good position after reduction 
and proper immobilization. Spiral, oblique, and comminuted fractures 
are more difficult to retain in proper anatomical adjustment by non- 




FiG. 354. — Drawing to show operation for musculospiral paralysis occurring as a 
complication of fracture of the shaft of the humerus. Small figure shows the nerve 
(A) pierced by the sharp point of the lower fragment and caught between the 
fragments, as found at operation. Large figure shows nerve {A) separated from 
the fragments of the humerus (the point of lower fragment being removed) by a 
flap of fascia (B), taken from the subcutaneous fascia at the posterior part of the 
incision (£>), which has been carried forward and is sutured to the biceps muscle (C). 
(See rontgenogram, Fig. 353-) 

operative means. It is probable that the comparatively frequent non- 
union, delayed union, or pseudarthrosis in brachial fractures is due to 
improper reduction and faulty immobilization. If reduction cannot be 
accomplished, the failure is probably due to intervening muscular tissue 
which is separating the ends of the fragments and may lead to non-union. 



346 



TREATISE OX FRACTURES 



If a dressing is applied which checks motion at the elbow- joint and pro- 
duces increased motion at the seat of fracture, pseudarthrosis is likely 
to result. In transverse, and in some spiral, oblique, and comminuted frac- 
tures, the following dressing is recommended : Surround the arm from 
elbow to shoulder with several layers of sheet- wadding, apply coaptation 
splints anterior, internal, posterior and external, place a small pad in the 
axilla, bind the arm to the chest wall and apply a shoulder cap for pro- 
tection and a small wrist-sling (Figs. 356— 356^). The weight of the 
forearm and arm will give some traction, but it is by preventing the over- 
riding of the fragments and by securing muscular rest that anatomical 
apposition is preserved and union secured by this dressing. In spiral and 

oblique fractures, when the fragments 
tend to become displaced, the Middle- 
dorp f triangular apparatus or the 
Monks splint may be tried. These cases 
generally require traction, and it may be 
obtained by the Hamilton adhesive 
plaster extension apparatus supple- 
mented by bed traction at night. In 
those cases in which one is unable to 
obtain anatomical apposition by any of 
these means, open operation and the 
use of a metal plate or band, nails or 
screws, or absorbable fixation sutures 
are advocated. 

Fractures in the upper third of the 
shaft may often be well treated by the 
simple dressing described for fractures 
of the upper end of the bone. In such 
cases the axillary pad may act better if 
wedge-shaped with the base of the 
wedge downward. In this form of 
dressing it is well to see that pressure is not great on the brachial artery 
by determining the presence of the radial pulse after the upper arm has 
been bandaged to the chest. 

When the shaft is broken above the insertion of the deltoid the upper 
fragment is liable to be pulled inward by the axillary muscles and the 
lower fragment pulled upward and outward by deltoid action. When the 
fracture is below the deltoid insertion the upper fragment may be dis- 
placed outward by the pull of that muscle, and the lower fragment have 
its upper extremity displaced toward the axilla by the biceps, triceps, and 
coraco-brachial muscles. 

Instead of using coaptation splints for fractures in the middle of the 
shaft, a moulded gypsum contour splint on the inner aspect of the arm 
from axilla to the palm of the semi-supinated hand may be employed. 




FlG. 355. — Padded wooden triangle for frac 
ture of shaft of humerus. (Pye.) 



FRACTURES OF THE HUMERUS 



347 




348 



TREATISE ON FRACTURES 



A short gypsum contour splint from shoulder to elbow added on the out- 
side of the arm sometimes may be needed for additional support. 

In fractures of the lower part of the shaft 
angular deformity is not uncommon. This 
is due to the elbow being flexed by the mus- 
cles attached to the condyles of the humerus. 
Accordingly these bring the upper end of the 
lower fragment forward, when gravity 
causes the forearm to drop. 

After reduction low 
shaft fractures are usually 
satisfactorily maintained 
in coaptation by means of 
a plastic contour splint 
moulded to arm, forearm, 
and palm with the elbow 
flexed at right angle and 
the wrist extended with 
the hand supine. The 
plastic splint should be re- 
inforced at elbow by addi- 
tional layers, or an angle 
of metal. The right angle 
posture of the elbow is not 
advisable as a rule in frac- 
tures close to or involv- 
ing the condylar end of the 

bone. Open fractures, which are not within a few days converted into 

closed fractures by primary closure or early delayed closure, may need 

fixation with fenestrated gypsum cases or bracketed splints permitting 

access to the infected wound. Such injuries are 

best treated by the methods employed in similar 

w r ar injuries. Skeleton splints of strong metal 

rods after the pattern of the Thomas extension 

splint for fractures of the lower extremity may 

be used. Suspension combined with traction is 

satisfactory if the patient is kept in bed. The 

Balkan frame may be adjusted for the carrying 

out of this method and permit voluntary motion 

of arm joints and fingers during the whole course 

of the treatment. 

After-results. — In uncomplicated fractures of 

the shaft of the humerus, union occurs in three 

to four weeks in children and in five to seven 

weeks in adults. With comminution of frag- 




FlG 



357- — Penhallow's abduction splint for fracture shaft of 
humerus. 




m 



Fig. 358. — Flexible coaptation 

splint made of adhesive plaster 

and narrow strips of wood. 



FRACTURES OF THE HUMERUS 



349 



ments union requires a longer time, possibly five to eight weeks. Frac- 
tures of the upper and lower third, uniting with the formation of con- 
siderable callus or deformity, are often followed by a moderate degree of 
impairment of motion at the shoulder- or elbow-joint, respectively. Wrist- 
drop from pressure on the musculospiral nerve and gangrene following 
vascular damage should not be too hastily referred to improper treatment. 

Pressure from tight bandaging or too firmly applied gypsum encase- 
ment may result in producing Volkmann's ischemic myositis. This possi- 
bility must be remembered; and its impending and early symptoms of 
pain, flexion of wrist and fingers recognized quickly. A few hours of 
unrelieved pressure may insidiously start this deforming and crippling 
affection of the muscles, nerves, and joints below the seat of pressure. 
Its onset must be met by prompt release of the constricting dressing, mas- 
sage, hot-water soaking, and elec- 
tricity. The pressure is not sufficient 
to cause great swelling or tumefac- 
tion of the fingers ; and the pain may 
be considered only sufficient to de- 
mand narcotic medication. Unwary 
attendants may not suspect source of 
difficulty, if a plaster-of -Paris case 
is being used, until trophic ulcers of 
the fingers and spastic contraction of 
the flexors of wrist and fingers have 
actually set in. The surgeon must 
beware of tight gypsum dressing in 
humeral fractures and fractures of 
the leg, when using this very valu- 
able form of external fixation. 

Failure of union occurs more fre- 
quently following fractures of shaft 
of the humerus than of any other 
bone. Von Bruns records 376 cases 
of ununited fractures among 1274 
cases of all bones. Of these he esti- 
mates only 56 per cent, of recoveries 
follow resection. In 187 cases of pseudarthrosis of humerus so treated, 
98 recovered, 3 were improved, y^ were unimproved, and 5 died. 

Causes of delayed union and pseudarthrosis may be interposed mus- 
cular tissue, injury of nerves or blood-vessels, or necrosis of ends of the 
fragments. General systemicconditions may here as elsewhere be the cause. 

The treatment consists in massage, injection of blood, or irritating 
substances such as tincture of iodine, the use of Bier's hyperemia; and 
finally open operation with resection of the fragments or the inlaying 
of an autoplastic bone graft applied laterally, or the insertion of an auto- 
plastic bone dowel into the medullary cavity. 




Fig. 359. — Fracture dressing for middle of shaft of 

humerus. Modification of Middeldorpf's triangle 

coaptation splint to arm. Binder in axilla around 

chest and arm needed to complete dressing. 



350 



TREATISE OX FRACTURES 



Fractures of the Lower End of the Humerus 

Varieties of Fractures. — The following forms of fracture of the lower 
end of humerus may be described: (i) supracondylar; (2) diacondylar; 

(3) intercondylar, T, Y, or 
atypical ; (4) separation of the 
lower epiphysis; (5) external 
epicondyle; (6) external con- 
dyle; (7) capitellum; (8) in- 
ternal epicondyle ; (9) internal 
condyle; (10) trochlea. 

In a consideration of frac- 
tures of the lower end of the 
humerus there are several very 
important facts to be borne in 
mind. The normal outlines 
(Figs. 362a and 362b) as 
shown by rontgenogram, 
should be carefully studied, in 
the adult and in children. Cer- 
tain varieties are seen more 




FlG. 360. — Apparatus for abduction and traction in fractures 
at upper end or middle of humerus. 



often in childhood, while other forms are met with more 
frequently in adult life. Fractures occurring during 
childhood are, as a rule, the result of indirect violence 
transmitted through the hand and forearm to the elbow. 
The majority of these fractures observed in children 
result from hyperextension, combined with abduction 
or adduction On the other hand, fractures of the 
lower end of the humerus observed in adult life are 
usually the result of machinery accidents or direct 
crushing injuries, and are seldom observed occurring 
from indirect violence as a result of a fall upon the 
hand with the elbow in a position of hyperextension. 
When fractures do 1 occur in adults from indirect force, 
the resulting fracture partakes of the nature of a sprain- 
fracture, as a rule. On account of this diversity in etiol- 
ogy and in lesions observed during childhood and adult 
life some authorities have been led to consider these 
fractures separately. 

Other differences observed in these two classes 
are that while, in children, marked deformity may 
be followed by distinct disability for a period of 
from six months to a year, still in the course of several 
years the absorption of callus, normal process of bony 
development, and adaptability of the parts to certain 
motions give a result that often can hardly be distin- 



FiG. 361. — Lines of frac- 
tures of the humerus: 
(a) through anatomical 
neck; (b) through tube- 
rosities; (c) through sur- 
gical neck; (d) through 
shaft; (e) T-fracture in- 
volving condyles. 
(Piersol.) 



FRACTURES OF THE HUMERUS 



351 



guished from a perfect one. In adults, however, the reverse is generally 
the case. Unless good or nearly perfect anatomical apposition of the 



Fig. 362a. 



Fig. 362b. 





* — ^ 





Fig. 363a. Fig. 363^. 

Figs. 362a and 362b. — Rontgenograms of normal adult elbow region. Anteroposterior and 

lateral views. 
Figs. 363a and 3636. — Rontgenograms of normal elbow region in child aged eleven years. 
Anteroposterior and lateral views. 

fragments is obtained, the resulting changes in the carrying angle and 
the development of osteoarthritis will be followed not only by deformity 
but by great impairment in function. 



352 



TREATISE OX FRACTURES 





Fig. 364. — The relations of the three bony points at the elbow in 
extension and in flexion (from behind). The marks are placed upon 
the internal and external condyles and olecranon process (diagram). 
(Cotton's Dislocations and Joint Fractures. W. B. Saunders Co.) 



Supracondylar Fractures (Figs. ^66a-^6yb). — In this form the frac- 
ture line occupies a more or less transverse position across the humerus 

just above the tips of the 
external and internal epi- 
condyles. It should not 
be confused with a low 
fracture of the shaft 
(Figs. 368(7 and 368b) or 
with a diacondylar frac- 
ture. In 103 fractures of 
the lower end of the hu- 
merus Plagemann found 
43 supracondylar frac- 
tures, Wendt in 134 
fractures, 61 cases, and 
in a later classification 
102 times in 302 frac- 
tures of the lower hu- 
meral end. Hilgenreiner found in no fractures of the lower end 21 
instances of this variety. Of the 43 supracondylar fractures of Plage- 
mann' s classification, all were observed in children between the ages of 
three to fourteen years, with the exception of 3 cases, occurring at 
eighteen, thirty-two and forty- 
eight years. 

The supracondylar fractures 
have been grouped in the follow- 
ing four classes by Kocher, and 
in these classes Plagemann divides 
his 43 cases as follows : 31 exten- 
sion fractures, 5 flexion fractures, 
5 abduction fractures, 2 adduc- 
tion fractures. 

In the extension fractures the 
line of fracture is from a point just 
above the attachment of the joint 
capsule on the anterior surface, up- 
ward and backward, and in addition the line of fracture runs from a plane 
on the external surface inward and upward. The fracture is the result 
generally of a fall upon the outstretched hand with the elbow in hvper- 
extension and abduction; the resulting fracture takes place just above 
the attachment of the joint capsule. This fracture is seen so frequently in 
children on account of the greater strength of the capsule than that of the 
attached bone. Fractures of this variety are not observed in adults 




<r 




Fig. 365. — Normal humerus (lower end) from in front 

and from outer side. (Cotton's Dislocations and Joint 

Fractures. W. B. Saunders Co.) 



FRACTURES OF THE HUMERUS 



353 



produced in this manner, but are the result of direct violence. The dis- 
placement backward of the lower end of the humerus may be great, but in 
other instances little dislocation is present. 



Fig. 366a. 



Fig. 3666. 






Fig. 366a. 



A 

Antero- 



-Supracondylar fracture of humerus, very little displacement of fragments 

posterior view. (See Fig. 3666.) 

Fig. 366ft. — Supracondylar fracture of humerus, extension type. Lateral view. (See Fig. 366a.) 



Fig. 367a. 



Fig. 367b. 





Fig. 367a. — Supracondylar fracture of humerus. Lower fragment has stripped off periosteum for a 
considerable distance from the diaphysis with resulting ossification along periosteum. Anteroposterior 

view. (See Fig. 367ft.) 
Fig. 367ft. — Supracondylar fracture of humerus. Lateral view. Extension type. (See Fig. 367c) 



In flexion fractures the line of fracture is low posteriorly and runs 
forward and upward. This form of fracture is very rare. Its mechanism 
23 



354 



TEEATISE OX FRACTURES 



is more or less theoretical. It is considered to be the result of a fall upon 
the extensor surface of the semi-flexed forearm, and it is thought that 
the line of force is transmitted directly upward in the line of the long 
axis of the humerus. When it is considered that the condyles occupy a 
plane anterior to this long axis, it can be readily understood how the 
condylar process may be fractured from the lower end of the shaft of 
the humerus and displaced upward. In fractures by extension the lower 
end of the upper fragment is displaced anteriorly by its fellow fragment, 
while in the flexion variety of fracture the lower end of the upper frag- 
ment is displaced posteriorly. 



Fig. 368a. 






Fig. 368b. 





Figs. 368a and 368ft. — Low fracture of the shaft of the humerus. This should not be confused with 
the supracondylar type of fracture. Anteroposterior and lateral views. 

In the abduction fracture the line of fracture runs from inward and 
below upward and outward. These cases appear to be the result of hyper- 
abduction with the elbow in full extension. 

In the adduction fractures the line of break is the reverse, being from 
below and on the outside to a point upward and inward. These fractures 
are the result of hyperadduction with the elbow in full extension. The 
last two varieties may be incomplete and show only an infraction of the 
outer or inner cortex of the bone. 

Symptoms. — The symptoms common to all fractures of the lower 
end of the humerus are pain, tenderness, swelling, ecchymosis, loss of 
function. In addition to these there are symptoms characteristic of the 
different fractures. In the fracture by extension the usual deformity is 
an anterior displacement of the lower end of the upper fragment forward 
and a posterior displacement of the lower fragment with the attached 
structures of the elbow-joint. The condition at first glance closely re- 



FRACTURES OF THE HUMERUS 



355 



sembles a posterior dislocation of the radius and ulna, and the two con- 
ditions should carefully be differentiated. This posterior displacement 
is due to the fracturing force, to the muscular pull upward and backward 
of the triceps muscle, and to- the upward pull of the biceps and brachialis 
anticus muscles. In addition the attachment of the forearm muscles to 
the lower fragments tends to rotate the lower fragment forward, produc- 
ing a certain degree of flexion. As a result of these forces the upper arm 
just above the elbow forms an obtuse angle with its opening posterior. 
Crepitus is present in all cases unless the displacement of the fragments is 



Fig. 369a. 



Fig. 3696- 





Fig. 369c. — Diacondylar fracture of humerus with marked lateral and posterior displacement of lower 

fragment. 
Fig. 3696. — Diacondylar fracture of humerus with little displacement of fragments. 

great or there is interposition of soft parts between the fragments. Ab- 
normal mobility is always present in complete fractures. 

In flexion fractures, which are rarely observed, the lower end of the 
upper fragment is posterior to the lower fragment. In these fractures, 
as well as in the abduction and adduction fractures, the deformity is not 
great. Crepitus and abnormal mobility are always present except in the 
incomplete form. 

Diagnosis. — This can generally be made by the presence of the above 
noted symptoms. The line of break may be distinguished with a very fair 
degree of certainty, if with general anaesthesia the surgeon's fingers of 
one hand are used to steady the shaft of the bone low down while the 
fingers of the other hand endeavor to make motions of the various 
components of the extremity of the humerus. The place and direction 
of the fracture will usually be indicated by the crepitus and the false 
point of mobility. Fluoroscopic and radiographic help is very valuable 



356 



TREATISE OX FRACTURES 



to confirm the clinical and anatomic diagnosis. It is not infrequently 
an indispensable aid. In fractures about the elbow- joint a general anaes- 
thetic usually should be given, not only for diagnosis but also for reduc- 
tion. The conditions should be differentiated from posterior luxation 
of the radius and ulna or of the radius alone ; and from fracture with asso- 
ciated luxation. The normal relative position of the epicondyles and the 
olecranon process will aid in arriving at a correct diagnosis. A radiogram 
in anteroposterior and lateral planes should be made before reduction for 
diagnosis and afterward to determine if anatomical reposition of the 
fragments has been accomplished. 

Diacondylar Fractures (Figs. 360^-3706). — Under this heading 
are included those transverse partially intra-articular fractures occurring 



Fig. 370c. 



Pig. 370&. 





Fig. 370c. — Oblique diacondylar fracture of humerus, with line of fracture running downward and 

outward (adduction type). 
FlG. 3706. — Oblique diacondylar fracture of humerus, with line of fracture running downward and 

inward (abduction type). 



above the line of the epiphysis. By some authors they are classified as 
low supracondylar fractures and by others this variety is not differentiated 
from a supracondylar fracture. These fractures, however, have been 
described under the term diacondylar by Kocher, by Chutro, and by 
Ashhurst. The line partakes of the character of a supracondylar fracture 
by extension. It is, however, lower, is more or less crescent-shaped and 
traverses the olecranon and coronoid fossa\ The lower fragment consists 
of the entire articular surface, together with the epicondyle, and there is 
generally a marked tearing up of the posterior portion of the periosteum, 
with generally lateral and often posterior displacement of the lower frag- 
ment. The line of break is above the epiphyseal line. 



FRACTURES OF THE HUMERUS 



357 



The mechanism of this fracture is essentially the same as that of a 
supracondylar fracture by extension, although it may be produced by a 
fall directly on the extensor surface of the flexed forearm. A rare 
variety of this fracture is the fracture of the Posadas type (Figs. 371 and 
3/2), detailed by Posadas and also by Ashhurst, in which the fracture 
produced by flexion causes the lower fragment to be displaced forward and 
to be complicated by a posterior dislocation of the radius and ulna. 

Symptoms. — To the general symptoms of fracture about the elbow 
there may be added crepitus, localized pain on pressure, occasionally abnor- 
mal mobility, and deformity. The crepitus can be obtained by flexion and 



Fig, 




Fig. 372. 




\ 



Fig. 371. — Diacondylar fracture of humerus, "Posadas type," with dislocation of head of radius. 

Fracture by flexion. Anteroposterior view. 

Fig. 372. — Diacondylar fracture of humerus, "Posadas type." Lateral view. 



extension of the elbow. Abnormal mobility is dependent upon the degree 
and extent of attachment of the joint capsule to the upper fragment. In 
some cases the abnormal mobility will be limited to hyperabduction and 
adduction. Deformity is not always present; when considerable dis- 
placement is present the lower fragment may be displaced laterally to 
either side and posteriorly. Anterior dislocation of the lower frag- 
ment is rare. An absolute diagnosis of this form of fracture is prac- 
tically impossible without the radiogram. Here particularly an 
anteroposterior and lateral view should be taken before reduction. 

Diagnosis. — This is made mainly by the radiogram. The condition 
should be differentiated from supracondylar fracture and separation of 
the entire lower epiphysis. From the latter it may be distinguished by 
the detachment of the entire lower portion of the diaphysis from the 
lower fragment, and one should be on g-uard to recognize this important 
point. In separation of the lower epiphysis small fragments of the diaphy- 
sis frequently remain attached to the epiphyseal cartilage. 



358 



TREATISE OX FRACTURES 



Intercondylar, T, Y, or Atypical Fractures (Figs. 373a, b and c). — 
These fractures are generally the result of direct violence, are frequently 
compound and are usually observed in adults. Of the eleven cases re- 

Fig. 373a. Fig. 373&. Fig. 373c 






Fig. 373a. — Intercondylar T or Y fracture of lower end of humerus. 
Fig. 373b. — Intercondylar Tor Y fracture of lower end of humerus. 
Fig. 373c. — Intercondylar atypical fracture of lower end of humerus. 

ported in Plagemann's statistics all cases were observed in adults with 
the exception of one seen in a twelve-year-old boy. The essential features 
are the separation of the condyles from the shaft and their separation 

from each other. The lines of fracture are 
rarely typical. There is often great displace- 
ment of fragments and marked injury of 
the overlying soft parts. Perforation of the 
soft parts and skin may be produced by 
the sharp ends of fragments. The upper 
line of fracture may be more or less trans- 
verse and about the line of a supracondylar 
fracture. Running from this line there is 
generally a vertical line of fracture separat- 
ing the two condyles irregularly. The 
separation of the condyles from each other 
may vary from a mere fissure to great dis- 
placement. At times marked comminution 
of fragments may be present. 

The fracture most frequently is the 
result of direct violence such as machinery 
accidents. Madelung considers that it 
may, however, be produced by the direct 




Fig. 374. — Skiagraoh showing lower 
epiphysis of humerus at five years and 
eleven months. (Anteroposterior.) 
(Ashhurst Surgery. Lea & Febiger.) 



wedge-like action of the 
upon the flexed forearm. 



ulna 



in 



ialls 



FRACTURES OF THE HUMERUS 



359 



Symptoms. — As most of these fractures are the result of direct vio- 
lence, the local signs of marked contusion of the soft parts are present. 




Fig. 375. — Skiagraph of lower epiphysis of humerus at eleven years (lateral). (Ashhurst 
Surgery. Lea & Febiger.) 



Swelling, ecchymosis, the formation of blebs, and superficial areas of 
gangrene are frequent. If the fracture is open, there are the evidences of 



Fig. 376. 








Fig. 


377- 




1 








H 3 < < 


I 














1 

1 


M 






""^ 



Fig. 376. 



-Epiphyses at eight 
years. 



Fig. 377. — Epiphyses at eight years. Same 
case as Fig. 376. Lateral view slightly dis- 
torted. (Cotton's Dislocations and Joint 
Fractures. W. B. Saunders Co.) 



such an injury. In typical fractures there is independent mobility of the 
condyles, broadening of the width between the condylar limits, mobility 
of the condyles upon the shaft of the humerus, and often marked de- 



!<30 



TREATISE OX FKACTFEES 



formity so that the position of the condyles may be anterior or posterior 
to the end of the shaft. The latter may at times be palpated between the 
separated condyles, while, on the other hand, the ulna may apparently be 
displaced between them. Crepitus is present in nearly all cases and is only 
limited by the degree of displacement of the fragments, the interposition 
of soft parts, or the presence of marked oedema. 

Diagnosis. — Cases of suspected intercondylar, T, Y, or atypical frac- 
tures should have lateral and anteroposterior radiograms made. In many 
obscure cases a positive diagnosis can be made only by this procedure. 

Separations of the Lower Epiphysis (Figs. 3800-381 b). — The lower 
epiphysis of the humerus is developed from four centres of ossifica- 
tion. A study of the radiogram 
of the lower end of the humerus 
shows that before the appearance 
of any of the centres the lower 
end of the diaphysis extends 



Fig. 379 



Fig. 378. 





Fig. 378. — Epiphysis at ten and one-half years. Anteroposterior view: (A) Capitellar epiphysis; 
(C) epitrochlear epiphysis; (D) radial epiphysis; (G) trochlear epiphysis. (Cotton's Dislocations 

and Joint Fractures. W. B. Saunders Co.) 
Fig. 379. — Epiphyses at ten years. Lateral view. Xote how far forward the epiphysis of the 
external condyle lies in relation to the shaft, and also how much of the olecranon is still cartilagi- 
nous. (Cotton's Dislocations and Joint Fractures. W. B. Saunders Co.) 



below the level of the olecranon and coronoid fossa?, that it is rounded. 
It is impossible to determine the internal from the external condyle 
without a study of the relative positions of the bones of the forearm. 
The centres of ossification appear in the following order : capitellum, 
from one to two years; internal epicondyle (epitrochlea), fifth 
to sixth year; trochlea, eleventh year; and external epicondyle, twelfth, 
year. The centres of ossification increase in size so that those of the 
capitellum, trochlea, and epicondyle are entirely fused from the twelfth, 
to the thirteenth year, and are entirely united with the diaphysis at the 
fifteenth year. The centre of the internal epicondyle does not fuse with 
the diaphysis until the eighteenth year. 

Separation of the lower epiphysis is observed during childhood up 
to about the fourteenth to the eighteenth years. When occurring near 



FRACTURES OF THE HUMERUS 

Fig. 3So<j. Fig. 3806. 



361 




/ 



If 




Figs. 380a and 3806. — Separation of lower epiphysis of humerus. Anteroposterior and lateral views. 



Fig. 381a. 



Fig. 3816. 





Figs. 381a and 38i5. — Separation of lower epiphyses of humerus, with small fragment of diaphysis 
attached. Anteroposterior and lateral views. 



362 



TREATISE OX FRACTURES 



the eighteenth year the lesion is usually a separation of the epiphysis 
of the internal epicondyle. The line of separation may be entirely through 
the epiphyseal cartilage, or there may be attached to the epiphyseal cartilage 
portions of the lower end of the diaphysis. The line of separation is 
variable and the portion of attached diaphysis is, as a rule, fairly constant 
when present. Separations that are produced by a fall upon the hand 
with the elbow in a position of full extension may have a portion of the 
posterior edge of the diaphysis attached. In addition there is usually 
marked stripping up of the periosteum. In separations produced by direct 



Fig. 382a. 



Fig. 382b. 





Figs. 382a and 382ft. — Fractures of external epicondyle of humerus. Tear-fracture. 

violence the portion of attached diaphysis will depend in a great measure 
upon the direction of the fracturing force. The fracture line may at 
times involve a portion of the epiphyseal line and then run upward 
through either condyle. 

Symptoms. — In addition to the usual signs of fracture, swelling, ten- 
derness, and ecchymosis, there is present crepitus, which is usually soft 
in character. Deformity when present consists of slight or moderate 
displacement posteriorly or laterally of the lower epiphysis. This may 
be recognized by the fact that the radius and ulna may be displaced poste- 
riorly or laterally at will by the surgeon and with little force. Abnormal 
mobility may be developed by the same manipulations. Many cases of 



FRACTURES OF THE HUMERUS 



363 



epiphyseal separation resemble sprains of the elbow and formerly were 
often so diagnosed. There is, however, persistent inability to move the 
forearm on account of localized pain and tenderness, and these two 
symptoms persist much longer than would be expected in a sprain about 
the elbow- joint. 

Diagnosis. — This may usually be made by the presence of persistent 
tenderness, pain on motion, soft crepitus, ability to produce an exag- 
gerated degree of abduction and adduction at the elbow- joint, and by 
careful interpretation of the radiographic findings. 



Fig. 383a. 



Fig. 383^ 







/ 



Figs. 383a and 3836. — Fracture of external condyle of humerus. Anteroposterior and lateral views. 



In a study of epiphyseal separations by the radiograms it is very 
important to bear in mind the time of appearance of these centres of 
ossification, and the date of their fusion with each other and with the 
diaphysis. In many instances a diagnosis by the radiogram of epiphy- 
seal separation can be made only by a comparison of the injured with 
the uninjured side before attempts at reduction have been made. In 
the early years of life diagnosis will depend entirely upon the altered rela- 
tion of the centres of ossification to the diaphysis. Later, during child- 
hood or before fusion of the epiphyses with the diaphyses, it may be pos- 
sible to distinguish epiphyseal separation here as elsewhere by the fact 






364 TREATISE OX FRACTURES 

that it is only in the very early years of life that a pure epiphyseal separa- 
tion occurs. After the sixth or seventh year, and in some instances earlier, 
it is noteworthy from a radiographic point of view that in epiphyseal 
separations a small portion of the diaphysis is very often separated from 
the diaphysis, and remains attached to and is displaced with the epiphysis. 
When callus has formed, it may be possible to make a diagnosis of epiphy- 
seal separation by radiograms from the presence and amount of callus 
formed after injuries in which, at the time of accident, a positive diagnosis 
was impossible. 

Fractures of the External Epicondyle (Figs. 2>%za, 382b). — Fractures 
of the external epicondyle are infrequently seen. The fracture may be 

the result of direct violence acting 
upon the external surface of the 
lower end of the humerus; or of 
indirect violence, as when a tear- 
fracture results from hyperadduc- 
tion of the elbow. It may be asso- 
ciated with posterior dislocation 
of the radius and ulna. 

Symptoms. — The symptoms of 
this fracture are localized pain, 
swelling and tenderness, slight 
crepitus over the external condyle, 
and the possibility of moderate 
hyperadduction of the forearm by 
forcible motion. 

Fractures of the External Con- 
dyle (Figs. 383^-3856). — Frac- 
• tures of the external condyle were 
observed by Plagemann in 15 in- 
stances out of 103 fractures of the 
■; lower end of the humerus. This 

Fig. 3 84.-Fracture of external condyle of the future is frequently observed in 

humerus - children. The line of fracture may 

run upward and outward obliquely from the joint surface, so that the 
detached fragment may consist of a part of the trochlea, the capitellum, and 
the epicondyle. In many instances the line of fracture begins near the ex- 
ternal trochlear ridge, and runs obliquely outward to a point below the epi- 
condyle. This form is especially seen in children, and at times great diffi- 
culty may be observed in deciding between a fracture of the condyle and 
an epiphyseal separation in which a considerable portion of the diaphysis 
is attached to the dislocated epiphysis. The fracture may be produced 
by a fall directly upon the external condyle; by a fall upon the hyper- 
flexed elbow, the external condyle being the point of impact; by hyper- 
adduction of the elbow, in which instance the fracture partakes of the 



FRACTURES OF THE HUMERUS 

FiC. 385a. Fig. 385^ 



365 



A...V • "C V.. 





Figs. 385a and 385ft. — Fracture of external condyle of humerus, fall upon hand with arm hyperextended. 

Anteroposterior and lateral vie ws. 






Fig. 386. — Fracture of external condyle before and after nailing. 



36G 



TREATISE ON FRACTURES 



nature of a tear-fracture; or by a fall upon the hand, with the elbow 
in full extension, the force being transmitted through the radius to 
the capitellum. 

Symptoms. — Examination shows localized pain, tenderness, swelling, 
and in some instances contusion of the soft parts over the external con- 
dyle. In addition there will be found crepitus, mobility of the condyle 
if the detached fragment is large, possibility of hyperadduction, and occa- 
sional displacement of the fragment upward. When the last condition is 
present, hyperabduction of the forearm is possible and a condition of 
cubitus valgus may be obtained. When marked displacement of the 



Fig. 387a. 



Fig. 387b. 










Figs. 387a and 387b. — Separation of the epiphysis of the capitellum of the humerus, to which is 
attached a small portion of the diaphysis. Anteroposterior and lateral views. 

fragment is present the roughened edge of the large fragment may be 
felt. Widening of the joint may be present. Dislocation backward of 
the ulna may be present as a complication. 

Fractures of the Capitellum (Figs. 387a, 387ft). — This fracture is 
one of the rarest of fractures occurring at the lower end of the humerus, 
Kocher described four cases under the classification of " fractura rotuli 
humeri." Cases have been reported by Stimson, Flint, Lorenz, Jopson, 
and Hahn. The injury consists in the separation of the articular surface 
of the capitellum and is entirely intra-articular. All of the reported cases 
appear to have been produced by transmitted force acting through the 
head of the radius, while the elbow was in a position of flexion, or by 
muscular action in which the head of the radius exerted upward pressure 



FRACTUEES OF THE HUMERUS 



367 



against the capitellum by the pull of the biceps muscle. Several reported 
cases were the result of crushing- injuries or direct violence. 

Symptoms. — The symptoms consist in pain, tenderness, swelling, and 
limitation of motion. This limitation is dependent in a great degree upon 
the displacement of the fragment. The elbow is generally held in a 
position of partial extension and passive motion may be complete. The 
condition resembles in certain ways a fracture of the head of the radius. 
Supination is limited and possible only with considerable pain. Palpation 
may determine the presence of the fragment near the head of the radius. 



Fig. 388. 



Fig. 389- 




/ 




% 




Figs. 388 and 389. — Fracture of the internal epicondyle of the humerus; the epicondyle is rotated 
laterally and displaced forward. Anteroposterior and lateral views. 

Fractures of the Internal Epicondyle (Figs. 388-391). — In many in- 
stances detachment of the internal epicondyle is a separation of the 
epiphysis, which only fuses with the diaphysis of the humerus at about the 
eighteenth year. This lesion is seen most often between the ages of ten 
and eighteen years, and consists in complete detachment of the epiphysis 
either alone or in conjunction with posterior luxation of the ulna and 
radius. The fracture or separation may be the result of direct violence, 
such as a fall upon the abducted arm ; more frequently, however, it results 
from hyperabduction of the elbow while in a position of full extension, 
forming a " sprain "- or tear-fracture. Attached to the epicondyle are 
the superficial flexor muscles and the internal lateral ligament. It is 
readily seen, therefore, how hyperabduction of the elbow may produce 



368 



TREATISE OX FRACTURES 



this separation. It is frequently found in conjunction with posterior dis- 
location of the radius and ulna, a lesion produced most frequently during 
hyper extension and hyperabduction of the elbow. The attached epicon- 
dyle is generally displaced forward and downward, and the ulnar nerve 
may at the same time suffer injury. 

Symptoms. — When the fragment is small and not displaced, the symp- 
toms consist in localized pain, a tenderness, and crepitus. When the 
fragment is displaced downward and forward there is swelling, pain on 
using the superficial flexor muscles of the forearm, ecchymosis, and crepi- 
tus during reduction of the displaced fragment. Motion at the elbow is 
not interfered with, as a rule, except for limitation due to pain. 



Fig. 390. 



Fig. 391. 





Fig. 390. — Fracture of the internal epicondyle of humerus. Marked downward and forward displace- 
ment of the epicondyle. 
Fig. 391. — Fracture of the internal epicondyle of the humerus without displacement of the fragment. 



Injury to the ulnar nerve, either immediately as a result of the fractur- 
ing force, or secondarily from involvement in callus, is a complication to 
be feared, yet is very infrequent. 

Diagnosis. — This can be readily made by the evidences of localized 
injury, crepitus, and the presence of the dislocated fragment at a point 
below and in front of its normal position. Rotation of the fragment 
is at times present. Wilms states that in all his cases of posterior dislo- 
cation of the forearm occurring from the tenth to the fifteenth years of 
life there was present a separation of the internal epicondyle. 

Fractures of the Internal Condyle (Figs. 392-394). — This fracture 
of the lower end of the humerus is unusually rare. This is shown by 
the statistics of Mouchet, 1 case in 170 fractures; Chutro, 2 cases in 106 
fractures; Kocher, 6 cases in 45 fractures; and Ashhurst, 4 cases in 56 



FRACTURES OF THE HUMERUS 



369 



fractures of the lower end of the humerus. The line of fracture as a rule 
runs from the inner border above the internal epicondyle downward and 
outward to the trochlear surface, and at times beyond the external border 
of the latter. The fracture in the majority of cases is the result of a fall 
upon the extensor surface of the ulna with the elbow in a position of 
flexion, the force being transmitted through the ulna to the trochlea with a 
resulting breaking off of the internal condyle. Fractures by abduction or 
adduction may be produced in childhood, when the resulting lesion is more 
of an epiphyseal separation with an attached portion of the diaphysis in 
the region of the trochlea. The displacement of the condyle is usually 
upward, inward, and backward; at times little if any displacement will be 
present. In the case illustrated, due to a fall upon the ulnar surface of 
the forearm with the elbow in a flexed position, the displacement was 
lateral, and the upper end of the condylar fragment was tipped forward 



Fig. 392. 



Fig. 393. 



Fig. 





Fig. 392. — Tear-fracture of the internal condyle of the humerus. 
Fig. 393. — Tear-fracture of the internal condyle of the humerus. 
Fig. 394. — Fracture of the internal condyle of the humerus. 

on extension of the forearm. At times when the displacement is posterior 
the ulna and radius may be displaced with the internal condyle. 

Symptoms. — The symptoms observed in fracture of the internal con- 
dyle are swelling, greatest about the internal aspect of the elbow, localized 
pain and tenderness, ecchymosis, abnormal mobility of the internal con- 
dyle revealed by palpation, broadening of the distance between the epicon- 
dyles, change in the relation between the epicondyles and the tip of the 
olecranon, crepitus, loss of the carrying angle, and marked deformity, 
if the radius and ulna are displaced posteriorly with the displaced inter- 
nal condyle. 

Diagnosis. — This can usually be made by the local signs of fracture. 
the broadening of the lower end of the humerus with mobility of the 
internal condyle, the possibility of excessive abduction and adduction with 
the elbow fully extended, and a study of the radiogram. When there is 
in addition a dislocation of the head of the radius, its head may be felt 
below and posterior to the external condyle. 
24 



3T0 



TEEATISE OX FBACTUBES 

Fig. 395- 




Fig 396. 





Fig. 397. 



Figs. 395, 396, and 397-— Fracture of the capitellum. (Courtesy of Dr. John H. Jopson.) 

It is to be remembered that some authorities apply the term "capitellum " to the entire external condylar 

process. 



FKACTUKES OF THE HUMERUS 371 

Fractures of the Trochlea (Figs. 395-397). — This is a rare fracture. 
By many authorities it is not even mentioned. Langier first described 
the fracture; Stimson reports two cases. The fracture consists in a 
chipping off of a part of the trochlear surface. From the few cases 
reported it is difficult to describe the mechanism of the fracture; it seems 
to occur from falls upon the hand with the elbow in a position of hyper- 
extension, the force being transmitted through the radius, the interosseous 
ligament, and the ulna. Falls directly upon the upper extensor surface of 
the ulna with the elbow in a position of partial flexion may transmit 
sufficient force to break off a portion of the trochlea. 

Symptoms. — The symptoms of a fracture of the trochlea are those 
of an indefinite injury to the elbow- joint. In addition to localized pain, 
tenderness, and effusion into the joint, it may be possible to palpate 
the displaced fragment. In a case reported by Stimson the fragment 
could be palpated beneath the epitrochlea. Both cases reported by 
Stimson were followed by good results and did not require removal of the 
displaced fragments. 

When the elbow has been crushed under heavy pressure or shattered 
by a gunshot injury, the lines of breaking are too irregular tO' classify. 

Complications of Fractures of the Lower End of the FIumerus 

The important complications of fractures at the lower end of the 
humerus are; open wounds, Volkmann's ischemic contracture, injury to 
important blood-vessels and injury to the musculospiral median, or 
ulnar nerves. 

Open fractures at the lower end of the humerus are sometimes seen, 
and usually are caused by direct violence. This is especially the case in 
the supracondylar fractures of the adult, and at times in the epiphyseal 
separations observed during childhood. 

Volkmann's Ischaemic Contracture. — This complication is observed 
not only in fractures about the elbow- joint, but also in fracture of the 
bones of the forearm. The condition, first described by Volkmann in 
1880, consists in a primary disturbance of the blood supply of the muscles 
from a dressing which is too tight or from other causes that produce pres- 
sure upon the muscles, and as a result marked ischsemia occurs. This 
compression is shortly followed by a true rigor mortis of the affected 
muscles, and later by hyaline degeneration and the replacement of the 
muscle fibres by connective-tissue. Not only does this change affect the 
muscles ; but the nerves appear to be similarly destroyed, though to a less 
degree. The sheath of the nerves is particularly involved. The de- 
generation, muscular and neural, may be complete or partial, and may 
involve some or all of the muscles and nerves. The flexor muscles seem 
to be most often involved. The lesion is not always due to the application 
of tight splints, dressings, or bandages. Cases have been observed in 
which no constricting dressing was used. In many cases, however, a 



372 TEEATISE OX FRACTURES 

dressing" is applied which at the time is sufficiently loose not to impede 
the circulation, but which causes constriction later when increased swell- 
ing has taken place, either from hemorrhage or oedema. In many of the 
cases the duration of the constriction has not been long. How rapidly 
the development of this grave ischsemia occurs is not definitely known, but 
certainly not longer than from six to twelve hours may suffice. The 
condition is seen particularly in children, and has been seen following 
thrombosis of the veins, compression of the main blood supply to the 
affected limb, and exposure to prolonged cold. Following the degenera- 
tion of the muscular fibres contractures rapidly develop in those muscles. 
Sometimes one group of muscles seems to be weakened by pressure on the 
nerve supplying them. This paresis permits the opposing muscles to con- 
tract. This is not a true condition of the Volkmann type. 

Symptoms. — In patients who develop Volkmann's ischemic contrac- 
ture it has been discovered that, while as a rule the dressing has not been 
applied so tightly as to be primarily uncomfortable, complaint of severe 
pain in the affected part is sometimes made in the first twenty- four hours. 
This may be looked upon by the patient's family and also by his physician 
as being the usual pain expected in fractures, and the dressing therefore 
may not be removed or even examined. Thus the only period at which 
successful measures can be adopted to prevent the development of 
ischsemic contracture passes without relief being given. In some cases the 
pain is not sufficiently severe to attract the attention of the family or 
nurses. When the patient is seen after the lapse of twenty-four hours, 
there may be found, on removing the splint or other dressing, that there is 
an area of superficial necrosis where the point of greatest pressure 
occurred. The hand will already, or at most within the following 
forty-eight hours, have assumed the characteristic attitude described by 
Volkmann. This superficial area of necrosis may subsequently slough 
and involve deeper structures than the skin. Examination of the extrem- 
ity will reveal a board-like hardness of the muscles and absence of 
voluntary contraction with painful and restricted passive motion. The 
fingers first show signs of contracture, the hand is in the position of 
pronation, the elbow semi-flexed, the wrist flexed or extended, the meta- 
carpophalangeal joint extended, and the interphalangeal joints flexed. 
Flexion of the wrist permits of extension of the fingers. The flexor 
group of muscles on forearm is permanently shortened, and shows marked 
wasting. Symptoms vary of course with variation in the groups of 
muscles or in the nerves involved in the constriction causing- the ischemia. 
The fingers are generally cold and blue, and at the end of twenty-four 
to forty-eight hours vesication may be noticed, particularly of the fingers. 
In severe cases there may be ischemic neuritis of the median and ulnar 
nerves, with reaction of degeneration, and loss of sensation in certain 
regions. Glossy skin, changes in the finger-nails, and trophic ulcers de- 
velop from slight mechanical injuries. The final stage is a claw-like de- 



FRACTUKES OF THE HUMERUS 373 

formity of the hands. Similar ischaemic myositis and contracture occurs 
in the legs. 

Treatment. — Volkmann's ischemic paralysis should be differentiated 
from the contractures of anterior poliomyelitis, Little's disease, and 
peripheral nerve paralysis. This ischemic contracture may, in many 
cases, be improved by the conscientious application of massage, soaking- in 
hot water, passive motion, and electricity if the condition is recognized 
early, and efficient and persistent treatment adopted. The result, how- 
ever, in a great measure will depend upon the original muscular and 
nerve destruction. In severe cases little permanent benefit will be obtained 
by non-operative means. Gypsum encasements applied too- firmly and not 
removed or loosened when the danger signal of pain is mentioned by 
the patient are probably the most frequent causes of the constriction. A 
pallor of fingers or toes is probably an early symptom likely to be over- 
looked. A greater degree of constriction which induces blueness of fingers 
or toes and swelling of these parts with numbness will probably lead to 
prompt removal of bandage or splint. It is the moderate complaint of 
the patient that is often the reason that ischsemic myositis of Volkmann is 
allowed to occur. When once established the time for immediate relief 
has passed ; but the surgeon can do much to arrest complete deformity and 
disability. The treatment, however, must extend over a long time and 
be judiciously applied with neurologic and orthopaedic skill. 

Various operative measures have been suggested and used to improve 
the condition. They consist of : lengthening the contracted tendons of the 
forearm; freeing by dissection the median and ulnar nerves from the 
surrounding cicatrix, and their transplantation to the subcutaneous tissue, 
myotomy and tenotomy of muscles and tendons; and resection of the 
radius and ulna with the removal of a portion of each sufficient to allow 
full extension of the fingers. In cases not operated upon, considerable 
improvement may be obtained by the use of suitable splints and apparatus, 
which correct to a degree the deformity, and prolonged massage and 
electric stimulation. 

Injury to important blood-vessels is rarely observed in fractures of 
the lower end of the humerus, except in, patients in whom considerable 
injury has been done to the soft parts in fractures due to direct violence. 
When severe injuries occur to the soft parts, the fracture may be an open 
one, and thrombosis, laceration of important blood-vessels, and large 
hsematomas may result. 

Injury to Nerves. — Injury to the musculospinal, median, or ulnar nerve 
complicates some fractures of the lower end of the humerus. Primary, 
intermediary, or secondary nerve lesions may result. Primary nerve 
lesions consist in laceration or compression of the nerve. Intermediary 
lesions, causing motor or sensory paralysis, may arise from injury follow- 
ing attempts at reduction or late manipulations of the fragments. Second- 
ary nerve paralysis is due to the pressure of developed callus. 



3T4 TEEATISE OX FEACTURES 

Some cases described as Volkmann's contracture of muscles prob- 
ably have been pressure damage to the nerves of arm or leg. Then the 
muscles, weak from paresis, are overcome by the normal contractility of 
the opposing muscle group. The true Volkmann's contracture is a de- 
generative change in muscles. 

Many of the nerve lesions complicating these fractures are not 
permanent and rarely require operation. Their frequency is shown by 
the statistics of Ashhurst, i case (median) in 56 cases; Coenen, 3 cases 
(musculospiral) in 31 supracondylar fractures; Destot, Vignard, and 
Barlatier, 1 case (musculospiral^ and 1 case (median) in 72 fractures 
above the elbow; Broca and Mouchet, 9 cases of nerve injury among j8 
elbow fractures. Miiller considers that nerve complications develop in 
one-fifth of all cases of supracondylar fractures (Ashhurst ). 

Treatment. — The anatomical reconstruction of the lower end of the 
arm bone in all these injuries requires that the fragments be returned to 
their normal relations. The functional reconstruction requires that the 
position of the bones be not allowed to interfere with the mechanical 
perfection of the elbow- joint, that the muscles have opportunity to act 
successfully, that damage to nerves and blood-vessels be repaired in a 
manner to correct wrist-drop from musculospiral palsy, pressure ansemia, 
and similar complications, and that the contour of the limb lose not its 
original symmetry and beauty. 

The full accomplishment of these ends is possible only when accurate 
diagnosis is united with mechanical precision and surgical judgment. It 
must be admitted at the outset that in some instances it will be impossible 
for the patient to obtain these essentials to perfection. Even operation, 
replacement, and direct fixation may prove incapable of giving a good 
result. The complicated mechanism of the elbow and its association with 
man's manual dexterity make its reconstruction after fractures an im- 
portant surgical problem. 

Fortunately the majority may be treated with practical success, if the 
practitioner in charge will take the trouble to carefully examine and com- 
pare both arms of the patient, under general anaesthesia, and use as a 
check the dry bones taken from a human skeleton. The character of 
the fracture, the nature of the displacement, and the way to correct the 
deformity will then usually be apparent to a medical graduate of average 
knowledge and ability. 

Elbow fractures are so notoriously liable to lead to suits for mal- 
practice that a considerable number of physicians hesitate to undertake 
their treatment. Anaesthesia for the primary examination, and frequent 
inspection of the limb entirely uncovered by fracture dressings, will 
probably reveal any condition wdiich renders the protection of consultation 
with a surgical specialist desirable. 

It is true that checks to the hinge-like action of the joint or a dimin- 
ished pronation and supination of the hand, from unreduced fragments, 



FRACTURES OF THE HUMERUS 375 

osteophytes, intra-articular adhesions, or extra-articular contractures and 
rigidity demand first consideration. Nevertheless, it is important to 
conserve the so-called carrying angle; its cosmetic, as well as its functional, 
value is important. 

The reconstruction of the elbow-joint is not, as a rule, a difficult 
problem, if the exact line or lines of fracture and the form of displace- 
ment are known, and if the doctor is alive to the mechanics of the under- 
taking. The various accessories of diagnosis and treatment, utilized in 
other fractures, generally permit the patient, unless the circumstances 
are exceptional, to secure a useful and undeformed joint. It is not just, 
however, to expect the average medical practitioner to obtain in the more 
complicated cases such uniformly satisfactory and perfect cures as the 
surgical specialist of metropolitan centres. The latter has a wide experi- 
ence, which may be readily supplemented by the expert radiographer and 
the aseptic plant of a modern hospital operating room. 

Secondary ankylosis of the joint is a common result of bad fractures 
and a likely occurrence in badly treated ones. This impaired mobility 
of the joint surfaces is to be averted by accurate replacement of the 
fragments, followed by careful massage and passive motion begun early. 
Prompt correction of the bony distortion is essential. 

In the treatment of the various fractures of the lower end of the 
humerus, several facts should be borne in mind. Before reduction it is 
wise to have anteroposterior and lateral view radiograms made. After 
reduction and whatever method of fixation has been used it is judicious 
to have the part radiographed again. Success in the treatment of these 
difficult fractures depends largely upon complete reduction and the reten- 
tion of the obtained anatomical coaptation of fragments under the guid- 
ance of radiograms. It is by accurate apposition of the fragments and 
fixation for the requisite time that exuberant callus, fibrous infiltration of 
the parts, and arthritic deposits of new bone are avoided. To insure the 
reduction of fractures of the lower end of the humerus, a general anaes- 
thetic should usually be employed as an adjunct. Some of these fractures 
are impacted and may require a considerable amount of force to break 
up the impaction and to permit proper reduction of the fragment. Reduc- 
tion may be accomplished only after hyperextension, longitudinal 
traction with countertraction, flexion, hyperflexion, lateral moulding, 
and manipulation. 

Usually reduction is far more readily accomplished than is the reten- 
tion of the fragments in their normal position. The method of retention 
which usually gives the best results, because it makes use of the triceps 
muscle, Nature's elbow splint, is the modified Jones position, that is. 
hyperflexion and supination. The best results are obtained by this posi- 
tion in the following fractures of the lower end of the humerus : supra- 
condylar fractures (with the possible exception of the Kocher flexion 
type) ; diacondylar fractures; separation of the lower epiphyses ; fractures 



376 



TREATISE OX FRACTURES 



of the external epicondyle, external condyle, internal epicondyle, and 
internal condyle. Hyperflexion of the elbow, as is shown so admirably 
by Ashhurst, gives the greatest stability to the broken lower humeral end. 
Flexion of the lower fragment on the forearm is prevented on account of 
the relaxation of the forearm muscles attached to internal and external 
epicondyles, and the point of insertion of the triceps muscle, being carried 
anterior to the long axis of the humerus, tends to hold the lower fragment 
in its proper relation with the upper one; thus posterior displacement of 
the lower fragment is impossible (Figs, 398 and 399). Robert Jones 
says that if we desire to improve statistics of good functional results, we 
must recognize the hyperflexed and supinated position as the chief ally 
in the treatment of severe injuries to the elbow. It seems possible that 

hyperflexion may not always be 
as satisfactory for fractures de- 
taching the external condyle as 
in those of the internal condyle. 
Sliding upward of the external 
condyle and the attached radius 
may be unobserved while the 
elbow is kept in the hyperflexing 
dressing. Such displacement 
would apparently be more read- 
ily recognized and corrected if 
the injury was dressed with an 
extended elbow-joint. The ex- 
tended position of the elbow 
maintained by an anterior con- 
tour gypsum splint, securing the 
normal carrying angle of the 
elbow, is often entirely satisfac- 
tory. The elbow should not be 
in quite full extension. 
In the treatment of the Kocher flexion type of supracondylar fracture 
continued hyperflexion and supination will be followed usually by good 
anatomical retention of the fragments, provided proper reduction is first 
obtained. If, however, the surgeon depends upon continuous hyperflex- 
ion without first having absolutely reduced the fragments, it is often im- 
possible to prevent recurrence of deformity. In a very small percentage 
of cases in which, because of marked obliquity of the line of fracture, it is 
impossible to engage the fragments, a better result may possibly be 
obtained by a right-angle anterior angular splint. This is a. dangerous 
posture for treating fractures of the lower end of the humerus, because 
of the risk of producing cubitus varus. It is probably preferable in such 
cases to obtain anatomical apposition by open operation and direct fixation 
with nails, screws or some similar device, when reduction is not easily 
maintained by the almost fully extended posture or hyperflexion. 





Fig. 398. — Diacondylar fracture of the humerus. Note 

the marked posterior displacement and moderate rotation 

of the lower fragment. (See Fig. 399-) 



FRACTURES OF THE HUMERUS 



377 



In the intercondylar, T, Y, and atypical fractures it is very difficult 
to properly reduce or mould the fragments into their normal relations 
and to maintain proper anatomical apposition. In these cases it is 
wise sometimes to adopt open operation and the direct fixation of 



the fragments. 



In fractures of the internal epicondyle it is generally possible to main- 
tain the fragment in its proper position by hyperflexion. If, however, 




i 




v 

J 



I! ft. 

\ UJ 

\ 2 

I it: 



Q 








Fig. 399. — Drawing to show the effect hyperflexion has in maintaining reduction of fragments. The 
central figure (made after rontgenogram', Fig. 398) shows the effect of the pull of the triceps muscle in 
maintaining deformity. The figure to the right shows this very clearly. The figure to the left shows the 
splinting action of the triceps muscle in maintaining apposition of fragments when hyperflexion is used 
after proper reduction. (Small figures modified after Ashhurst.) 



this cannot be done the almost extended position or open fixation is 
advisable. In some instances subcutaneous nailing may answer. In 
troublesome fractures of the trochlea and capitellum open operation and 
the removal of the detached fragment is recommended. 

In the reduction of these fractures at the lower end of the humerus 
an assistant should grasp the arm firmly, steady it, and at the proper 
time make countertraction ; the surgeon should first hyperextend the 
elbow-joint, separate impacted fragments, and then, by means of manipu- 



3T8 



TEEATISE OX FRACTURE: 



lation, engage the ends of the fragments; when this procedure has been 
accomplished, direct traction should be made upon the condyles ; internal 
rotation should be corrected and the elbow slowly flexed, hyperflexed, 
and the forearm supinated (Fig. 401). If proper reduction is accom- 
plished, cubitus valgus (Figs. 402(7-404) or varus (Figs. 405-408) will 
be rare in the types of fracture in which dressing in hyperflexion is used. 
The degree of hyperflexion Avill depend upon the amount of swelling pres- 
ent. In- cases with much swelling it is always wise to abstain from using 

flexion for a few days. As a 
rule it should stop at the point 
i which causes discomfort or 

which is likely to cause com- 
pression of the brachial artery. 
It is dangerous in the early days 
of severe fracture in out-patient 
hospital practice because the 
great swelling may endanger 
circulation and be unrelieved. 
The radial pulse should always 
be felt, after the bandage or 
other dressing has been applied, 
and an unobstructed beat of 
the radial artery proved to 
be present. 

There are several suitable 
dressings for maintaining this 



O 




Pig. 400. — External condyle fracture of humerus which 
was treated by flexion and subsequently by open opera- 
tion and nailing. 



flexed position. One is an ad- 
hesive plaster strap so applied 
as to give an even pull upon the 
surfaces of the forearm and 
arm. This strap should be two 
inches in width. It is applied 
by placing its centre over the 
upper outer surface of the arm, 
and the two ends are then car- 
ried around the extensor sur- 
face of the supinated forearm at a point about two inches above the radial 
styloid. A wrist-sling made of a cotton roller bandage surrounded by 
rubber tubing may be used to support the limb (Figs. 409 and 410). 
A good form of dressing is that made by the cotton roller bandage 
properly applied. 

In young children liable to disarrange the dressing, a tightly fitting 
undershirt with sleeve long enough to come beyond the fingertips of the 
injured limb may be satisfactorily utilized. The shirt is put on with the 
broken arm through its appropriate sleeve, the elbow acutely flexed, and 



FBACTUKES OF THE HUMERUS 



379 



the end of the sleeve closed with needle and thread. Then the loose end 
of the sewn sleeve is sewed firmly to the neck of the shirt in front of the 
child's opposite sternoclavicular joint. If the adhesive strap method is 
used its ends, as Cotton has wisely said, should cross at an angle and 
be pinned as well as stuck together. 

The hyperflexion and supination or extension with supination should 
be maintained for at least three weeks. The dressing should be inspected 
every other day during the first week and twice weekly during the succeed- 
ing two weeks ; it should be changed whenever necessary. At the end of 
ten days or two weeks the acuteness of the hyperflexed position or the 






Fig. 401.— Method of reduction of fractures of the lower end of the 

humerus. Longitudinal traction and countertraction, supination, 

flexion, and hyperflexion. 

extended elbow position, whichever has been chosen, may be decreased 
slowly so that at the end of the fourth week the elbow is brought to a 
right angle and the limb is bandaged and carried in a sling. Passive 
motion should be begun early and carefully and should at no time be 
sufficiently violent to cause pain. Careful massage of the soft parts may 
be indulged in from the end of the first week. It may even be started 
immediately after injury by an experienced surgeon' Early passive 
motion, if injudiciously employed, and forcible manipulation are liable 
to dislocate fragments, increase the formation of excessive callus, and 
delay the resumption of normal motion. 



380 



TEEATISE OX FRACTURES 

Fig. 402a. Fig. 4025. 




Figs. 402a and 402b. — Old fracture of external condyle of humerus, untreated. 
(See Figs. 403 and 404.) 



Fig. 403. 



Fig. 404. 




Figs. 403 and 404. — Right cubitus valgus due to an unreduced displacement upward of external 
condylar fragment. Old fracture of external condyle of humerus, untreated. (See Figs. 402a and 402b.) 



FKACTUEES OF THE HUMEEUS 



381 



The near-extended posture of the elbow-joint, the acutely flexed posi- 
tion, and occasionally right-angle flexion may be used in most of these 
lesions ; provided that the medical attendant knows the line of fracture, 
reduces the fragments, keeps them reduced, inspects the arm frequently, 
and prevents the moderate displacement which may result in a secondary 
cubitus varus or valgus. 

The fracture dressing should be simple but efficient. Fixation in the 
extended position of the elbow with the 
hand supinated has been advocated. This 
posture is valuable in maintaining the 
divergent angle between the axes of the 
arm and forearm and permitting easy rec- 
ognition of any tendency to abnormal 
adduction or abduction. Thus the production of cubitus varus or valgus 
is rendered unlikely. The joint should be almost but not quite fully ex- 




Fig. 405. — Deviating flat splint of wood for 

fractures through the internal condyle of 

the humerus when it is desired to treat 

injury with extended elbow. 



Fig. 406a. 



Fig. 406ft. 





Figs. 406a and 4066. — Old fracture of internal condyle of humerus showing loss of carrying angle (cubi- 
tus varus). (See Figs. 407 and 408.) 



tended. The extended elbow in condylar fractures may be maintained by a 
deviating anterior wooden splint properly padded or by anterior or pos- 
terior moulded splints of gypsum or other plastic material. The position is 
not especially inconvenient or irksome to the patient. It should not be full 
extension. This is irksome and there is a risk of overextension displacing 



382 



TEEATISE OX FRACTURES 



fragments. The gypsum encasement may be used, if it is split so as not 
to make injurious circular constriction in case of unexpected swelling. 

In some cases the difficulty of diagnosis, the gravity of the lesion of 
the bones and soft parts, the unusual displacement of the fragments, the 
development secondarily of new bony processes, and atrophic modification 
of osseous surfaces may cause partial or complete ankylosis of the joint 
and deformity of the limb. It is always wise, therefore, to give a guarded 
prognosis, until the ultimate outcome is clearly established. A very little 
callus in the olecranon fossa will greatly limit extension. 

After-results. — In cases of fracture of the lower end of the humerus 



Fig. 407. 



Fig. 408. 




Figs. 407 and 408. — -Right cubitus varus from unreduced displacement of internal condyle. Old 
fracture of internal condyle of humerus not properly treated. (.See Figs. 406a and 4066.) 



the after-results will depend almost entirely upon the perfection of reduc- 
tion accomplished and the proper anatomical retention of fragments. 
If these two objects are thoroughly met, the after-results should be satis- 
factory. In adults the after-results are not quite so good, as a rule, as in 
childhood. This is probably due to the greater violence necessary in the 
production of fractures in adults, with its consequent greater detachment 
of periosteum, and severer comminution of fragments. In childhood 
nature has a way of so readjusting the parts that in after years perfect 
functional results may be obtained in injuries which at the time of con- 
valescence appeared hopeless in that regard. 

The end results in fractures of the lower end of the humerus of 
various authors are given by Ashhurst as follows : 



fbactub.es of the humebus 



383 













Results 










■r. 

2 




















6 
B 


1/3 
3 


■Sj 


xn rt 




Author 


o 


£ 






> 


d 


"c? 


+-> 




o 




+3 


5c 


U3 

3 


t/3 

3 


g 6 w 


'0 






3 






3 


3 




'3 




2 


2: 


Oh 


^ 


U 


O 


>.s*a 


ft 








Po- ce^i. 


Per Cf7z/. 


Per ce w/. 


Per cent. 






Aslihurst 


56 
3i 


47 

28 


38 (8I.O) 

7 (25-0) 


4(8) 
12 (43) 


4(8) 

7 (25) 


I (2.0) 






Coenen 


I (3.0) 


I 




Cotton 


3 1 


27 


5 (18.5) 


10 (37) 


11 (40) 


1 (3-7) 






Destot, Vignard and 


















Barlatier 




39 


11 (28.2) 


28 (71.8) 










Hilgenreiner 


21 


14 


3 (21.3) 


4 (28.5) 


4 (28.5) 


1 




2 



Cubitus Valgus; Cubitus Varus. — The " carrying angle "of the arm 
is that angle formed at the bend of the elbow by lines drawn in the axes of 
the arm and forearm, while the elbow-joint is fully extended and the hand 



Fig. 409. 



F/g. 410. 




Fig. 409. — Method of maintaining hyperflexion of elbow by adhesive plaster strip. 
riG. 410. — Rubber tubing sling. Finished dressing in position of hyperflexion. 

supinated. It normally disappears when the forearm is pronated or when 
the forearm is flexed on the arm. It is due to the normal obliquity in the 
transverse plane of the articular surface of the lower end of the 
humerus and the slight obliquity of the transverse plane of the upper 



381 



TREATISE OX FRACTURES 



articular surfaces of the bones of the forearm. In a series of 5*0 cases ex- 
amined by Ashhurst, the carrying angle varied from 162 to 178 degrees. It 
is greater in women than in men on account of the greater width of the 
female pelvis. Cubitus valgus and cubitus varus are terms given to 
changes in this angle which may result from deformity occurring after 
fracture at the lower end of the humerus. Cubitus valgus is an outward, 
or abduction distortion due to an increase in the normal carrying angle; 
cubitus varus, an inward or adduction deformity due to a decrease in that 
angle. The angle is designed by nature to permit the human animal to 
carry in his hand a large object, such as a bucket of 
water, without striking his thigh as he walks. Cubitus 
varus is commonly called the " gunstock " deformity. It 
is liable to occur after fracture of the internal condyle, 
especially if the right-angle wooden splint is used as a 
fixation dressing. Either the valgus or varus deformity 
may result after supracondylar fractures of the lower 
end of the humerus, although cubitus varus is the more 
frequent. It has been considered to occur frequently 
after fracture of the internal condyle and epiphyseal 
separations. This deformity is also frequent after frac- 
tures of the lower end of the humerus, when the surgeon 
has treated the injury in the semi-flexed position of a 
right-angle anterior splint or a right-angle trough splint. 
These tend to displace the fragments, because of the 
different levels of the radius and ulna. This permits 
sliding upward of a detached internal condyle, and 
rotation of the articular fragment of the humerus in 
supracondylar and epiphyseal fractures. The opposite 
displacement, cubitus valgus, is less usually seen. If the 
fracture is thoroughly reduced and the arm treated by 
the hyperflexed position or the almost completely ex- 
tended position, the normal carrying angle is much more 
likely to be preserved. Perfect reduction must, however, 
be assured at the time the fracture is put up in a 
retentive dressing. 
The operative treatment of either condition consists in an osteotomy 
or osteectomy of the humerus in the supracondylar region. For cubitus 
valgus the osteotomy should be performed from the inner surface, and 
for cubitus varus from the outer surface of the humerus. The line of 
osteotomy should be complete, so that the entire thickness of the bone is 
severed. In marked cases a wedge of bone should be excised, otherwise 
the deflection will not be corrected, except in instances of slight deformity. 
The correction is then made, the wound closed, and the arm dressed in 
full extension and supination on a splint or in a gypsum case, being careful 
to maintain the correct carrying angle. In mild cases, however, it is 



Fig. 411. — Outward 
deflection of normal 
forearm for weight 
carrying. (Stimson.) 



FRACTURES OF THE HUMERUS 



385 



scarcely necessary to correct either of these deformities. Unless the 
conditions are moderately great, they interfere but little with function. 

Cubitus varus or " gunstock " deformity is the commoner of the 
two, and interferes greatly with carrying a bucket or bag, because the 
burden tends to strike the thigh when the patient walks. He must com- 
pensate for the brachial deformity by greatly bending his trunk toward 
the side of the distorted arm if the weight be heavy. 

The " gunstock " deformity of the arm, termed cubitus varus, is due 
to angular deviation, or upward with or without inward displacement, 




Fig. 412. — Nor- 
mal angle of 
bones of forearm. 
(Allis.) 



Fig. 413. — Diagram of 
carrying angle. (After 
Ashhurst. Courtesy- 
Lea & Febiger.) 



Fig. 414. — Patient showing cubitus valgus after recovery 

from fracture of internal condyle. Episcopal Hospital. 

(Ashhurst 's Surgery. Lea & Febiger.) 



of the whole lower end of the bone or of its internal condylar portion. 
It may be a primary or a secondary distortion. This can be avoided if 
the medical man is not forgetful of its possibility, and constantly com- 
pares the injured with the uninjured arm in the extended position with 
the hand fully supinated. The normal carrying angle is greater in men 
than in women and in adults than in children. It also varies in individuals 
of the same age and sex, and is not shown when the hand is pronated. 
Its loss by deformity from fracture is a cosmetic blemish, and, if marked, 
interferes much with the utility of the limb. It is probably caused by 
the fracture dressing or the sling, in which the arm is carried, lifting 
the ulna upward toward the shoulder or permitting the ulna, acting as 
a lever, to displace in the direction of adduction the fragment detached 
25 



386 TREATISE ON FEACTUEES 

from the shaft of the humerus. It may perhaps occur from gravity when 
an imperfectly dressed fractured arm is laid across the chest of a recum- 
bent patient. 

Cubitus varus is found in supracondylar fractures, fractures near 
the epiphyseal line, T and Y and comminuted fractures, and fractures of 
the internal condyle. The opposite distortion, cubitus valgus, takes place 
when abnormal abduction of the forearm at the elbow is produced by 
angular or rotary displacement outward of the entire condylar extremity 
or the fractured external condyle. 

The medical man should remember that there is normally no lateral 
movement of the elbow- joint, and that the hinge is primarily constructed 
by the articulation of the ulna with the humerus. The wrist-joint, on the 
other hand, is primarily an articulation of the radius with the carpus. 

Secondary cubitus varus and cubitus valgus may perhaps be due to 
an imperfect growth at the epiphyseal line after fractures in that region 
among children. The surgeon is not responsible for its existence. It is 
then not a deformity due to a primary rotation or an early deviation 
occurring during treatment of the fracture. 

Summary of Treatment of Fractures of Humerus 

Upper End. — Restraint of motion, using chest as thoracic splint, 
perhaps compress in axilla, elbow flexed and perhaps carried a little 
forward, wrist-sling. Sometimes shoulder cap, preferably of plastic 
materials. Occasionally traction in abduction. Rarely operative fixation 
with nail or screw or suturing of periosteum with catgut. 

Shaft. — At upper part, similar to fractures of upper end of bone; in 
middle, narrow coaptation splints of wood or metal but using also thorax 
as splint, and sometimes adding shoulder cap. Extension weight some- 
times hung from elbow. Occasionally gypsum contour splint on outer 
aspect or inner side of arm. Lower part of shaft and the true supracon- 
dylar fracture, right angle splint of wood or metal or of plastic material 
with elbow flexed at right angle and hand supinated. Elbow should not 
be supported by a sling lest it cause overlapping. Operation occasionally, 
to fix with plate or screws or absorbable tube of catgut or fascia, and 
sometimes after deformed or non-union. 

Lower End. — Usually by acute flexion of elbow, maintained by ad- 
hesive plaster band, hand covered with mitt or sleeve stitched to opposite 
sternoclavicular region, by bandage. Sometimes near-extended elbow 
maintained by anterior deviating wood or metal splint or plastic material 
to sustain carrying angle. Avoid right-angle anterior splint or posterior 
trough right-angle splint, as a rule, though such may be used for a few 
days, while swelling is great. Operation required occasionally when 
reduction impossible or deformed union present. In all fractures of 
humerus be sure of reduction before applying dressing. 




Fig. 414a. — Showing balanced suspension and traction method of treating a fracture of neck of humerus. 
Patient exercising the elbow-joint, (Courtesy of Dr. H. H. M. Lyle.) 



CHAPTER XVII 

FRACTURES OF THE RADIUS AND ULNA 

Anatomy. — The radius (Fig. 415), the outer bone in the forearm, 
takes little part in the formation of the elbow hinge; but it plays the chief 
role at the wrist. The principal parts of the radius are the disk-like head ; 
the neck, a constriction below the head; the tuberosity below the head for 
the insertion of the biceps tendon; the shaft, which, like the ulna, is, on 
cross-section, three-sided like a prism, but enlarges as the lower extremity 
is reached. The flattened lower end presents two* surfaces, the volar a,nd 
the dorsal, and has the styloid process below at its outer corner. The head 
of the radius presents a cup-like depression at its top to articulate with the 
capitellum of the humerus ; at its lower end it articulates with the scaphoid 
and semilunar bones of the carpus and laterally with the head of the ulna. 

The ulna (Fig. 416), the inner bone of the forearm, is parallel to 
and a little longer than the radius. The upper extremity has on its anterior 
aspect the greater sigmoid notch, which articulates with the trochlea of 
the humerus. The olecranon is the hook-like upper extremity of the ulna. 
The triceps muscle is inserted upon the olecranon dorsally; the upper 
portion of this process curves forward over the greater sigmoid cavity, 
and on extension fits into the olecranon fossa at the back of the lower end 
of the humerus. The anterior and upper part of the ulnar shaft ter- 
minates in the coronoid process, which fits into the coronoid fossa of the 
humerus on flexion of the elbow. On the outer side of the base of the 
coronoid process is an oval depression for articulation with the margin 
of the head of the radius, which rolls in this lesser ulnar sigmoid cavity 
during rotation of the hand. The shaft of the ulna becomes smaller in 
circumference toward its lower extremity and terminates in its head or 
capitellum, from which extends a pointed process called the styloid 
process. The lower end of the ulna articulates laterally with the side of 
the base of the radius. 

The trochlea of the humerus articulates with the greater sigmoid 
notch of the ulna, the humero-ulnar articulation; the capitellum of the 
humerus with the upper articular surface of the head of the radius, the 
humero-radial articulation, and the radial notch of the ulna with the 
articular circumference of the head of the radius, the proximal radio- 
ulnar articulation. Surrounding these three articulations there is a com- 
mon capsular ligament. In addition there is a radial or external lateral 
ligament, an ulnar or internal lateral ligament, and the annular or orbicu- 
lar ligament which surrounds the neck of the head of the radius for three- 
quarters of its circumference, the remaining portion being formed by the 
radial articulation of the ulna. 

387 



388 



TEEATISE OX FRACTURES 



The carrying angle of the arm and forearm at the elbow- joint nor- 
mally averages for boys, 168 degrees; for girls, 178.24 degrees 
(Ashhurst). This is the result of the fact that the plane of the trochlea is 
not at a right angle to the axis of the shaft of the humerus, but is placed 
obliquely, so that when the forearm is extended the axes of the humerus 
and forearm bones form an obtuse angle outward at the elbow hinge. 

The distal radio-ulnar joint is formed by the articular surface of the 
ulnar notch of the radius and the circumference of the capitellum of the 



Anterior border 

Groove for 
external os met.pol. 

Groove for 

external brevis pol. 

Styloid process 



Fig. 415. 





Head 

Neck 

Bursal surface 

Tuberosity 
Biceps tendon 



Oblique line 
Nutrient foramen 

Interosseous border 



Fig. 416. 

Tip of olecranon 
Greater 
sigmoid cavity 
Coronoid process — -/ 



Tuberosity 



W^ 



Anterior border 



Nutrient canal 
Interosseous border 



Sigmoid cavity for ulna 
Semilunar surface 
Scaphoid surface 



Articular facet 

for radius- 

Styloid process - 



Fig. 415. — Right radius; flexor surface. 
Fig. 416. — Right ulna; outer surface. 

ulna, and also by the triangular cartilaginous disk between the head of 
the ulna and the cuneiform bone. In addition there are fibres known 
as the anterior and posterior radio-ulnar ligaments. 

Pronation and supination are produced by rotation of the upper end 
of the radius on a longitudinal axis through its head and neck; and at its 
lower end by the rotation of the radius around the head of the ulna. 
The entire movement may be likened to rotation around a cone with its 
apex through the head of the radius and its circumference at its lower 
extremity. The range of motion is about 180 degrees around the base 
of the cone. 



FRACTURES OF THE RADIUS AND ULNA 



389 



Surface Markings. — The radius is palpable throughout its entire ex- 
tent, except for a small portion of its upper third. The head of the 
radius can be readily palpated, and this fact is of importance in determin- 



ing fracture of the radius. 



By placing the thumb over the head of the 

BCD 






Fig. 417. — Ossification of radius (A) at birth; (B) at two 

years; (C) at five years; (D) between eighteen and nineteen 

years, (a) Centre for shaft; (b) for lower epiphysis; (c) for 

upper epiphysis. 

radius, which may be felt just below the external condyle of the humerus, 
its mobility may be determined by pronation and supination of the fore- 
arm. In thin persons the tuberosity of the radius may also be felt. Of 
special importance in examination of the forearm are the normal radial 




Fig. 418. — Lower portion of left humerus with radius and ulna. Incomplete double fracture of 
the radius and ulna. The radius sustained an incomplete fracture both at the middle and at 4 cm. 
from the wrist-joint. The ulna sustained incomplete fracture at the lower third, at 7 cm. and at 
4 cm. from the end. From a boy fourteen years of age whose arm was torn off by machinery. (M litter 

Museum, No. 1307.) 

arch in the lower one-third of its palmar surface and the relation of the 
radial styloid in comparison with the ulnar styloid. Normally it will be 
found to be about a quarter of an inch below the ulnar styloid. 

The ulna can be felt throughout along its posterior border. Especial 
attention should be given to the position of the olecranon in relation to 



390 



TREATISE OX FRACTUEES 



the internal and external condyles of the humerus. In thin persons the 
coronoid process may be felt anteriorly on semiflexion of the elbow- joint. 

Fractures (Combined) of Radius and Ulna 

Etiology. — The cause may be direct or indirect violence. When direct 
violence has been operative, the cause is generally a blow, a kick, or a fall 

Fig. 419a. Fig. 4196. 





Figs. 419a and 419ft. 



-Fracture of shafts of radius and ulna. Marked overriding of frag- 
ments. Anteroposterior and lateral views. 



upon the forearm at the site of fracture. When indirect violence has been 
received, the cause is usually a fall upon the hand. In cases due to direct 
violence the seat of fracture is at or near the same level in both bones. 
When due to indirect violence the level of fracture in the two bones varies. 
Generally the site of fracture is at a higher place in the ulna than in the 



FRACTURES OF THE RADIUS AND ULNA 



391 



radius. A few rare cases of fracture by muscular action have been re- 
corded in which there was a contributing form of external violence, as in 
shovelling" or in rising upon the hands while on the ground. The frac- 
ture is rarely observed in children. Oberst, in a study of 92 cases of 
fracture of both bones, found the fracture at the same level in 50. In 31 



Fig. 420a. 



Fig. 4206. 





4H 



^- 




Figs, 420a and 4206. — Multiple incomplete fractures of shafts of radius and ulna. Antero- 
posterior and lateral views. 



the fracture of the radius was higher, and in n the fracture of the ulna 
was higher. In 4 instances the fracture involved the upper third, in 36 
cases the middle third, and in 52 cases the lower third and the junction 
of the lower and middle thirds. 

The line of fracture may be transverse, oblique, or spiral, and rarely 
longitudinal. The fracture may be partial, incomplete, subperiosteal, or 



392 



TEEATISE OX FEACTUEES 



" green-stick " (Figs. 418-421). A fairly common form of fracture 
observed at the lower third of the radius is the " cortex fracture ' y 
seen in children. In childhood the cortex is flexible, and as a result of 
impaction and slight flexion the cortex bulges outward. In adults the 
same form of violence will produce a transverse fracture. 

The fracture may be open, comminuted, or multiple. Extensive dam- 
age to the soft parts is the result of severe direct violence, and marked 
displacement of the ends of the fragments may be the result. 

Displacements. — The displacements noticed in fractures of both bones 
of the forearm depend in a great degree upon the fracturing force, the 



Pig. 421a. 



Fig. 4216. 




Fig. 421a. — Fracture of shafts of radius and ulna. Overriding of fragments. 

Fig. 4216. — Complete fracture of shafts of radius and incomplete fracture of ulna. Union without 

reduction of fragments, with posterior deformity. 

position of the fracture, its character, the pull exerted by attached muscles, 
and the weight of the forearm. In fracture of the upper third of both 
bones there is in many instances not only fracture, but also a dislocation of 
one or more bones or an associated fracture of the lower end of 
the humerus. 

In fracture the result of severe direct violence the displacement of 
the fragments may be considerable. The usual displacements are angular, 
rotary, overriding. In many fractures of both bones little if any dis- 
placement is noticed, with the exception of slight angulation due to the 
fracturing force, or to the weight of the forearm. Of special importance 
are : supination displacement of the upper fragment of the radius in fore- 
arm fractures between the attachment of the biceps and the insertion of 
the pronator radii teres; inward or central displacement bringing the 



FEACTUEES OF THE KADIUS AND ULNA 



393 



ends of the fragments of the radius and ulna together in fractures about 
the middle third (Fig. 422) ; displacements due to the pull of the pronator 
radii teres, causing pronation of the upper fragments of the lower middle 
region of the forearm; and that caused by spasm of the quadrate pronator 
in fractures at the junction of the middle and lower thirds or below that 
point, which results in pronation of the hand with the rest of the lower 
arm supinated or held in mid-supination. 

Symptoms. — The symptoms of simultaneous fracture of the radius 
and ulna will depend to a great degree upon the character of the injury. 
In incomplete, subperiosteal, " green-stick " and cortex fractures de- 
formity may be absent or slight. The usual symptoms then will be local- 




Fig. 422. — Drawing to show the usual displacement of fragments in fractures of the shafts of the radius 
and ulna. Note overriding and pulling over of lower fragment of radius by the action of the pronator 

quadratus muscle. 

ized pain, tenderness on pressure, disinclination to use the part, and 
swelling. When deformity is present, it is of the angular variety. One 
bone may be the seat of a complete fracture, in which case crepitus may be 
obtained, while the other bone may be incompletely fractured. Fractures 
of the above character are observed up to almost the fifteenth year. 
Sometimes the fracture is not recognized at the time of injury, and the 
local symptoms may be ascribed to a severe contusion and the true con- 
dition understood only at the end of several weeks, when the presence of 
moderate callus formation will attract the attention of the child's parents. 
Incomplete fracture of both bones, in addition to the local signs usual 
in partial fracture, show displacement of the fragments, deformity, 
crepitus, and often marked swelling of the forearm and bruising of the 
soft parts. 



394 TEEATISE OX FRACTURES 

Complications. — The complications of fracture of both bones of the 
forearm that may arise are gangrene, Volkmann's ischemic contracture, 
diffuse cellulitis, union with angular displacement, union with fusion of 
the fragments by a bridge of callus (Fig. 423), delayed union, non- 
union, pseudarthrosis, and persistence of a diminution of supination, 
due to rotary displacement of the upper or lower fragments of the radius, 
according to the situation and direction of the line of fracture. 

Diagnosis. — The diagnosis of incomplete fractures may usually be 
made by the persistence of pain, tenderness on pressure, and change in 
the contour of the bones at the point of suspected fracture. In complete 
fractures the diagnosis as a rule is obvious. Radial and ulnar injuries 
resembling fractures, especially fracture of the incomplete variety, should 
be carefully radiographed. In some few cases a positive diagnosis is 
otherwise impossible. 

Treatmemt. — For incomplete fractures in which there is no deformity, 
the indications of treatment are simple. In such fractures of the upper 




Fig. 423. — Bone of right upper extremity; union with co-ossification. The fracture occurred above 

the middle of the forearm. The uniting callus is smooth but exuberant, and firmly binds the radius 

and ulna together. The forearm is fixed midway between pronation and supination. It is difficult to 

state in the radius the precise location of the fracture. (Mutter Museum, No. 1307.02.) 

two-thirds of both bones the arm and forearm should be immobilized on 
an anterior angular splint from middle of arm to the wrist for a period 
of about three weeks. A moulded gypsum splint, similarly applied to the 
flexor surface of the forearm and the front of the lower part of the 
arm, controls the elbow- joint and fixes the fragments in the upper fore- 
arm admirably. 

For incomplete fractures, in which there is angular deformity, the 
deformity must be corrected at once by forcible bending, even if it is 
necessary to make the fracture complete to obtain correction of the dis- 
placement. Here, as elsewhere, sometimes careful bending may recon- 
struct the broken bone without causing complete fracture with displace- 
ment. This is the ideal reduction. In a few cases reduction may be 
accomplished by traction on the hand, countertraction above the elbow 
with the latter semiflexed, and local moulding and pressure at the seat 
of fracture. In fractures of this form involving the upper two-thirds of 
the forearm immobilization after reduction is best accomplished by the 



FRACTURES OF THE RADIUS AND ULNA 



395 





33 



^ 2. 




1 • J 




""3. 

S^ 





396 



TREATISE OX FBACTUBES 



application of an anterior angular splint applied to the arm and forearm, 
with the elbow in a position of semiflexion and the hand in full supination 
(Fig. 424). Full supination is advised, because a wide separation of the 
radius and ulna is obtained in this position, and when the pull of the 
biceps muscle tends to supinate the upper fragment of the radius the 
lower fragment is brought into its correct position by this procedure. 
If, after the application of the anterior angular splint, there is noticed any 
tendency toward posterior bowing at the seat of fracture, this may be 
corrected by the application of an additional posterior splint applied from 
the olecranon to the wrist (Figs. 424-425??). A better plan is the appli- 
cation of moulded gypsum splints or an encasement to maintain the 
desired position. 

Reduction of the fragments in complete fractures will often call for 
not only considerable force, but also considerable manipulation of the 



Fig. 426a. 



Fig. 4266. 




Fig. 426c. — Photograph showing areas of pressure necrosis from poorly padded anterior and posterior 

splints applied too tightly. 
Fig. 4266. — Posterior deformity from green-stick fracture of shafts of radius and ulna before reduction. 

fragments. The arm should be flexed at the elbow, an assistant should 
make steady countertraction above the elbow, and the operator traction 
b}^ grasping the forearm above the wrist. By using considerable force 
and skilful manipulation reduction in many cases may be accomplished. 
A general anaesthetic is advisable whenever reduction is painful or diffi- 
cult. After reduction has been obtained the parts should be immobilized 
as above described. In fracture of the lower third of the shafts or at the 
junction of the middle and lower thirds of both bones, immobilization of 
the elbow-joint is not always necessary. As a rule the fragments may be 
held properly reduced by the use of an anterior splint, extending from the 
fold of the elbow to the metacarpophalangeal joints of the fingers, and a 
posterior splint, applied from the same level above to the mid-metacarpal 
region below. In the application of splints in fractures of the bones of 
the forearm a preliminary bandage next to the skin should not be applied. 
Such bandaging is seldom if ever necessary underneath a splint dressing 
anywhere. A longitudinal pad to maintain separation of the radial from 



FBACTUKES OF THE RADIUS AND ULNA 



397 



ulnar fragments should not be used; it is of little value in preventing 
bridges of callus, and may cause very harmful pressure. Proper reduc- 
tion and fixation are the means of obviating such complications. Gypsum 
contour splints are especially valuable because they fit accurately. A 
slight depression in the surface may be made with the surgeon's thumb 
at any spot where a little additional pressure is needed to keep a frag- 
ment in position. This is done just before the splint hardens. Atten- 
tion should be paid to preventing the recurrence of angular deformity, 
and the dressing should be carefully watched so as to avoid undue con- 
striction, Volkmann's ischemic myositis, or pressure necrosis (Figs. 



Fig. 




Fig. 427. — Tear-fracture of the tip of the olecranon process by muscular action. 
Fig. 428. — Fracture of olecranon exostosis from direct pull upon flexed elbow. 

426^ 426ft). The development of non-union, pseudarthrosis or faulty 
union should be carefully observed and appropriate means for their cor- 
rection instituted. 

In fractures of radial shaft below the insertion of the round pronator 
the upper fragment may be pronated strongly. The surgeon should see 
that the lower part of the bone is not allowed to unite in a supine position. 

In cases of fracture of both bones, in which the fragments cannot be 
properly reduced or in which reduction cannot be anatomically main- 
tained, open operation with direct fixation is advised. The develop- 
ment of pseudarthrosis or non-union is usually due to faulty immobiliza- 
tion or to the interposition of soft parts. In many cases of delayed 
union longer immobilization with general treatment will effect a cure. In 



398 



TEEATISE OX FRACTURES 



pseudarthroses open operation is often necessary, with the resection 
of the ends of the fragments and the insertion of an autogenous bone- 
graft or intramedullary peg, or the fixation of the freshened bone ends by 
plates, kangaroo tendon sutures, wires, nails or screws. 

Results. — Union occurs in the majority of cases in from three and 
a half to six weeks. The subsequent usefulness depends in great measure 
upon the character of the fracture, its position, and the amount of callus 
necessary to obtain union. When excessive callus occurs, pronation and 



Fig. 429. 



Fig. 430. 





y 




Fig. 429. — Incomplete fracture of base of olecranon process. Direct violence. 
Fig. 430. — Comminuted fracture of olecranon. Direct violence. 

supination may be greatly interfered with and fusion of the two bones 
by callus may occur. In cases in which pronation and supination are 
impaired, without the presence of excessive or bridge-like callus to account 
for the condition, the disability may be due to the fact, as pointed out by 
Konig, that union occurs with the lower fragment pronated and the upper 
fragment supinated, rotary malposition being the result. Supination of 
the hand is therefore restricted to the limit which it is possible for the 
upper fragment to take. When union takes place with the fragments dis- 
placed towards each other and the hand pronated, the interosseous mem- 
brane is so stretched at the point of union of fragments by moderate rota- 
tion that supination is limited. 



FKACTUKES OF THE KADIUS AND ULNA 



399 



Isolated Fractures of the Ulna 
Fractures of the Olecranon. — Fractures of the olecranon process 
(Figs. 427-432) may be the result of direct violence, of muscular action, 
or of a combination of both. Those resulting from direct violence, such as 
a fall upon the olecranon or the extensor surface of the upper forearm, 
are usually transverse in direction; they may, moreover, be comminuted 
or compound. Fractures the result of muscular action are always trans- 
verse and single. Olecranon fractures may be associated with fractures 



Fig. 431. 



Fig. 432. 




Fig. 431. — Transverse fracture of olecranon process. Muscular action. Very little separation of 

fragments. 
Fig. 432. — Transverse fracture of olecranon process. Marked separation of fragments. 

of the coronoid process. That fractures of the olecranon are not so 
frequently the result of direct violence alone is shown by the frequent 
absence of local trauma. Many of these fractures unquestionably are the 
result of the sudden flexing of the elbow by the muscles — the triceps holds 
the olecranon firmly and, as the patient falls upon the hand or semiflexed 
forearm, an extreme force is indirectly brought to bear on the ulna at the 
point of articulation of the olecranon with the trochlea of the humerus, 
and fracture results. Most fractures resulting from direct violence are 
comminuted in character. 

Displacement. — In considering the displacement that may occur in 
fracture of the olecranon it should be remembered that the three articu- 



400 TKEATISE OX FEACTUEES 

lations of the elbow- joint are surrounded by an articular capsule. This is 
attached to the ulna just in front of the tip of the olecranon and extends 
forward on the lateral aspect of the olecranon to a point anterior to the 
coronoid process. It forms with the annular ligament a firm support to 
the component bones of the joint. Further support is given by the attach- 
ment of the triceps muscle, which is chiefly inserted into, and completely 
surrounds, the olecranon process; it also gives lateral expansion to the 
ulna and antebrachial fascia. It is for this reason that fractures of the 
olecranon, transverse in character and at a position well back towards the 
tip, are often observed without any displacement. The fragment is mostly 



Fig. 433. — Drawing to show the action of the triceps muscle in causing separation of fragments 
in fracture of the olecranon process. (Made after Fig. 432.) 

intra-articular and is held attached to the remaining portion of the ulna 
by the articular capsule and by the lateral expansions of the insertion of 
the triceps muscle. When, however, the fracture line is situated more 
anteriorly, separation occurs, as it also may when the fracture is the 
result of muscular action. In such instances the lateral expansion of the 
insertion of the triceps muscle and the articular capsule are torn; and 
therefore displacement readily occurs by the action of the triceps muscle 
(Fig. 433). This displacement is always greater on flexion at the elbow 
and usually may be made to disappear on full extension. 

Symptoms. — The usual signs of fracture, swelling, ecchymosis, effu- 
sion of blood into the elbow-joint, local pain, deformity (Figs. 435a and 
435 fr) > an d tenderness are present. The arm may be carried in any position. 
There is generally actual loss of power of extension. Extending power, 



FKACTITKES OF THE KADIITS AND ULNA 



401 



however, may be present to a limited degree when the periosteum and the 
lateral expansion of the triceps tendon are not completely torn. Extension 
is best tested by having the patient attempt it against resistance. Crepitus 
can generally be obtained, even in those cases in which there is consider- 
able separation of the fragments, by manipulation of the fragments during 




Fig. 434. — Fracture of olecranon treated in extended position. It is better to use a moulded splint, or one 
cut to correspond with the deviation of the axes of arm and forearm, instead of this splint not so shaped. 

full extension at the elbow. Separation of the fragments may be detected 
by palpation. A radiogram will always make the diagnosis certain. A 
source of error possible in radiographic diagnosis is the belief that a par- 
tially ossified process or a normal epiphyseal line in a young subject is a 

Fig. 435a. Fig. 4353. 





Figs. 435a 



[35b. 



-Photographs showing slight deformity after incomplete fracture at base of 
olecranon process. Union with posterior angulation. 



fracture line. The olecranon may have one or two centres of ossification. 
These centres increase in size until the sixteenth or seventeenth year, when 
complete ossification of the epiphyseal line takes place. Separation of 
the olecranon epiphysis is rare, and can only be diagnosed by radiographic 
examination and careful comparison with its fellow of the opposite arm. 
26 



402 TREATISE ON FRACTURES 

The insertion of the tendon of the triceps muscle, which extends the 
forearm at the elbow, is into the back and the upper surface of the olec- 
ranon and into the deep fascia covering the forearm. In front of the 
tendon at its insertion into the bone is a bursa. This may become dis- 
tended from inflammation after injury and its contained fluid give rise 
to crepitation on pressure somewhat like that obtained in palpating a 
fracture. This condition has a diagnostic importance. Separation of 
the epiphysis may occur, between the age of ten years, when the ossific 
centre appears, and sixteen years, when it unites with the shaft. The 
epiphysis is a mere plate forming the upper surface of the olecranon and 
is buried, as it were, in the tendon of the triceps muscle. Its separation 
resembles in appearance a fracture of the adult olecranon high up, and 
requires similar treatment. The tendinous envelop may sometimes be 
torn. There will be little displacement of the epiphysis unless the tendon 
is torn when the diastasis occurs. Laceration of the tendon of the triceps, 
occurring with or without fracture, may make suture of its fibres wise 
surgery. If, in the presence of clinical localizing signs of injury to the 
epiphysis, the radiograms show distinctly a marked displacement as com- 
pared with the other side, one is justified in making a positive diagnosis. 
The surgeon should make himself familiar with the radiographic appear- 
ances of the bones at the elbow- joint at various ages. The ossific centres 
are often mistaken for fracture fragments, Flexion of the elbow causes 
great separation of the fragments if the tendinous fascia is much torn. 
This fact may sometimes aid in differentiating epiphyseal separation or 
true fracture from incomplete ossification of the entire olecranon 
in children. 

Treatment. — Reduction of this fracture, as a rule, is readily accom- 
plished by full extension of the forearm and traction above the olecranon. 
Union in many cases is fibrous and not bony. This is due to a certain 
amount of separation of fragments and the interposition of small por- 
tions of fascia. Open operation should be followed by firm bony union. 
Non-operative treatment consists in nearly full extension at the elbow, 
and the application of a well-padded splint to> the flexor surface of the 
arm, forearm and hand, extending from the axilla to the palm of the hand. 
This splint should be held firmly to the arm with circular strips of adhesive 
plaster and a bandage; an additional strip should be placed above the 
olecranon and run downward in a diagonal direction, to hold the olecranon 
firmly apposed to the remaining ulnar fragment (Figs. 436 and 437). If 
no separation of fragment is present, immobilization may be obtained 
by a well-padded internal right angular splint. The internal splint should 
hold the elbow-joint at a right angle (Fig. 438). Look out that a pres- 
sure sore is not produced over the epicondyle. 

In young adults, members of the working class and others, whose 
occupation depends in a great measure upon the ability to fully extend 
the arm, and also in all instances where great separation of fragments is 



FRACTURES OF THE RADIUS AND ULNA 

Fig. 436. 



403 






Hsjft 



•t 



f 




Fig. 437. 



Fig. 438. 




... 



s 




Figs. 436 and 437. — Straight splint applied to internal surface of arm and flexor surface of forearm 
for fractures of the olecranon process. Note application of adhesive straps. One strap particularly 

should be placed just above the process. 

Fig. 438. — Application of the internal right-angle splint for fracture of the olecranon process when 

there is no separation of fragments. 

present, operation with fixation with suture of the fragments is recom- 
mended. Convalescence is more rapid, union is bony and a strong useful 
arm is obtained. A U-shaped incision, approximation of the fragments 
and suture with twenty-day chromic catgut or kangaroo tendon, closure 



404 TEEATISE ON FRACTURES 

of the wound, and the application of a splint holding the arm in a little 
less than full extension will meet all operative indications (Fig. 439). 

Subcutaneous nailing or subcutaneous suturing through transverse 
drill tunnels in the two fragments may be employed for coapting 
the fragments. 

With the non-operative treatment, the splint should be discarded at 
the end of four weeks, and active and passive motion given. Massage 




Fig. 439. — Method of suture in fractures of the olecranon process attended by separation 
of fragments. Two lateral sutures of kangaroo tendon approximate the fragments and 
interrupted sutures of chromic catgut hold together the torn periosteum. The skin and 
subcutaneous tissue wound is closed by interrupted sutures of linen thread and the arm 
immobilized on a splint in a position of almost full extension. 

should be instituted at the end of the first week, or even earlier. In opera- 
tive cases the splint may be omitted earlier. 

Results.— Fractures of the olecranon treated by non-operative means 
are followed by good functional results in the majority of cases. Fibrous 
union is more frequent than is generally supposed, and while the function 
of the part may be decreased somewhat, it is good for all practical pur- 
poses, except in those instances in laborers where the degree of extension 
is of paramount importance. Bony union results generally in those cases 
in which there is no separation of fragments and in the operative cases. In 
some instances it is remarkable that, although there is a markedly appre- 



FRACTURES OF THE RADIUS AND ULNA 



405 



ciable gap between the fragments and only fibrous union, extension with 
considerable power is present. The olecranon is similar to the patella 
in its function, and demands a very similar treatment when it is frac- 
tured. It is probable that suture of the capsule may be as efficient as 
sutures carried through the fragments. In this it resembles to a certain 
extent fracture of the patella, though in the latter injury there is more 
opportunity for separation because of the greater tendency to wide lacera- 
tion of the muscular tendinous envelope. 

Fractures of the Coronoid Process (Figs. 440-444). — This fracture 
was considered extremely rare. The radiograph has, however, revealed 
a more relative frequency of its occurrence. Although many authorities 



Fig. 440. 



Fig. 441. 





Fig. 440. — Fracture of coronoid process of ulna. 

Fig. 441. — Fracture of the coronoid process of the ulna, complicating a posterior dislocation 

of radius and ulna previously reduced. 

consider isolated fracture of the coronoid process extremely rare, except 
as an accompaniment of backward or lateral dislocation of both bones of 
the forearm, the three cases here illustrated, in which there was no dislo- 
cation or tendency to dislocation present, were seen by Doctor Kelly. 
Its occurrence is probably not very unusual. 

The mechanism of this fracture is not definitely understood. Some 
surgeons consider it the result of a fall upon the ulnar border of the 
hand with the forearm in a position of partial flexion, the force being 
transmitted through the ulna to the coronoid process, which is broken 
by counter-pressure against the trochlea of the humerus. By other writers 
it is believed to be due to action of the brachialis anticus muscle, and to 
partake of the nature of a tear- or sprain-fracture. This seems improb- 



406 



TEEATISE OX FRACTURES 



able, as the muscle is not attached to the tip of the process, but at its 
base. Other authorities attribute its occurrence to hyperflexion of the 
elbow-joint. It is suggested that coronoid fracture may result from a 
fall upon the hand with the forearm in a position of partial flexion, trans- 
mitting the vulnerating force through the interosseous ligament from the 
radius to the ulna and thus driving the coronoid process against the 
trochlea. The force thus transmitted may or may not be severe enough 
to produce an accompanying dislocation backward of both radius and 
ulna at the elbow. An accompanying fracture of the anterior portion 
of the head of the radius has been described by some authors. The line 
of fracture may be at the tip or at the base of the process. Carl Beck and 
Bloodgood have given interesting reports of cases of this injury. The 



Fig. 442. 



Fig. 443. 



Fig. 444. 





Fig. 442. — Fracture of coronoid process of ulna. 

Fig. 443. — Fracture of coronoid process of ulna complicating a fracture of the olecranon process. 

Fig. 444. — Fracture of base of coronoid process of ulna complicating a diacondylar fracture of the 

humerus. 

former believes it to be overlooked because of its frequent association 
with posterior or lateral dislocation of the bones of the forearm or with 
fracture of the olecranon or of the radius. 

Displacements. — In fractures of the process unaccompanied by pos- 
terior dislocation of both bones of the forearm, displacement of the process 
is slight. This is due to the firm attachment of annular and lateral liga- 
ments and the tendon of the anterior brachial muscle which is attached 
to the base, not the tip, of the process. When there is present a posterior 
dislocation of both bones of the forearm, the fragment tends to remain 
in normal relation with the anterior surface of the trochlea, and to be 
separated from its attachment to the shaft of the ulna. 

Symptoms. — The symptoms of fracture of the coronoid process unac- 
companied by luxation of the bones of the forearm are often indefinite. 
Diagnosis may be dependent upon excluding all other fractures in the 



FBACTURES of the badius and ulna 



407 



elbow region. If these fail to explain the symptoms presented by the 
examiner's investigation, coronoid fracture may be strongly suspected. A 
definite diagnosis may be made, if there is localized pain and tenderness, 
increased by flexion at the elbow, local swelling, retention of the normal 
landmarks about the elbow, and a suggestion of crepitus on deep palpa- 
tion over the coronoid. A radiographic examination will clear up doubt. 
When there is present a dislocation of both bones posteriorly, fracture of 
the coronoid process may be diagnosed by the comparative ease with which 
a recurrence of the dislocation is reproduced when the elbow assumes a 
partially flexed position. 

Treatment. — In fracture accompanied by dislocation, the latter con- 
dition should be reduced by traction with countertraction, followed by 
attempts to extend the joint and suddenly flex 

it. After reduction the forearm is carried to s&w), 

a position of hyperflexion. This position should 
be maintained for from two to three weeks, 
using the form of dressing described under 
fractures of the lower end of the humerus, and 
then may be kept in flexion greater than a right 
angle for about two weeks longer. When there 
is no dislocation present, there is generally little 
displacement of the coronoid fragment. In 
this condition the arm and forearm should be 
immobilized at a right angle on an internal 
angular splint, with the hand midway between 
pronation and supination for three to four 
weeks. Very slight passive and active motion 
should, as in all fractures, be started early ; pas- 
sive movements may be started at four weeks. 
Complete or nearly complete immobilization is fig. 445.— Fracture of coronoid 

. ............ process of ulna. 

perhaps more essential in this than in other 

fractures, so that anatomical apposition of the. fragments is main- 
tained, callus formation thus lessened, and therefore the possibility 
of interference in subsequent joint function decreased. If there is 
marked interference with flexion of the elbow, excision of the detached 
fragment may be necessary. This should not be done for mere separation 
of the fragment. In operative attacks care should be taken not to injure 
the median or musculospiral nerve. Attempts to suture the bone in its 
normal relation are said to be usually unsuccessful. Operation generally 
means excision of the fragment to relieve chocking of the hinge of the 
elbow or chiselling away a mass of callus about an old fracture of the 
coronoid process. 

Results. — The after-results are generally favorable. Subsequent re- 
turn of full function may be expected except in cases with complications, 
unrecognized or unrelieved. 




408 



TREATISE ON FRACTURES 



Fractures of the Shaft of the Ulna — Etiology. — Isolated fractures 
(Figs. 445-448) of the shaft of the ulna are usually the result of direct 
violence, generally received by a fall directly on the posterior surface of 
the ulna or by a blow being received with the arm uplifted to protect the 
body or head. This is the so-called " parry fracture." Fractures by 
indirect force, such as a fall upon the hand, are extremely rare, as are 
also fractures by violent bending, torsion, pronation, or supination. The 
fact that the lower end of the ulna has little part in the wrist- joint proper 



Fig. 446a. 



Fig. 4466. 





Fig. 446a. — Fracture of shaft of ulna, upper third. 
Fig. 4466. — Fracture of shaft of ulna, lower third. 

protects it from transmission of impacts upon the hand. The radius is the 
chief factor in the construction of the joint between forearm and carpus, 
and is therefore the more apt to sustain fracture from falls upon the hand. 
When the fracturing force is severe, the fracture may be multiple or 
compound. A not uncommon complication of fracture of the shaft 
of the ulna is an anterior dislocation of the head of the radius. This 
complication is considered by Helferich and Dorfler to> accompany frac- 
tures of the shaft only when the fracture involves the upper third of the 
ulna. Oberst and also Wilms do not coincide in this view, and report 
cases in which the fracture involved the middle third of the ulna. This 
lesion is most frequently the result of a direct blow received upon the 
posterior aspect of the outer surface in the upper or middle third of the 
shaft of the ulna. Isolated fracture of the ulnar shaft is less common 
than fracture of both the radius and ulnar shafts. 



FKACTUBES OF THE KADIUS AND ULNA 409 

Displacement. — In uncomplicated fracture of the ulnar shaft, the pres- 
ence or absence of displacement is dependent upon the degree of the frac- 
turing force, the nature of the fracture, and its position. The occurrence 
of deformity from overriding of fragments, even in oblique fractures, is 
greatly limited by the unbroken radius acting as a splint. Study of radio- 
graphs and of patients seems to show that the displacement of the frag- 
ments is not uniform. There is doubtless a certain tendency in fractures 
below the middle for the lower fragment to be displaced toward the radius 
in complete fractures by the pull of the pronator quadratus muscle. An 

Fig. 447. Fig. 448. 




Fig. 447. — Fracture of shaft of ulna, middle third. 
FlG. 448. — Multiple fracture of shaft of ulna, lower third. 

important factor, however, in producing this displacement is the weight 
and position of the hand held in ulnar adduction, which tends also to 
throw the upper end of the lower fragment toward the radial shaft, giving 
rise to angular deformity. In incomplete fracture the angle of de- 
formity is generally toward the radius. When the break is complete 
and above the middle of the shaft, the anterior brachial muscle may draw 
the upper fragment into flexion. This may be accompanied by an anterior 
luxation of the head of the radius. 

Symptoms. — The symptoms of incomplete or " green-stick " fractures 
of children may be limited to localized swelling, ecchymosis, pain and 
tenderness on pressure, especially on attempting to squeeze the shafts of 
the ulna and radius together. No deformity may be present until callus 



410 TREATISE ON FRACTURES 

has formed if the break is subperiosteal and without displacement. Crepi- 
tus is necessarily absent. In complete fractures there will generally be 
noted localized swelling, ecchymosis, pain, crepitus, deformity, disinclina- 
tion to use the forearm, and marked pain on attempting forcibly to extend 
the elbow, and pain particularly in pronation or supination of the hand. 
Shortening will be absent unless there is an accompanying dislocation of the 
head of the radius ; then it may occur. The subcutaneous situation of the 
ulna renders palpation of its entire length easy and diagnosis of deformity 
not difficult. Do not forget the possibility of a forward dislocation of 
the head of the radius in isolated fracture of the ulna. Always examine 
carefully the relations of the bones comprising the elbow-joint when the 
ulna seems to be broken near the upper part of the shaft. Radiographic 
diagnosis is important in obscure cases. 

Treatment. — The reduction of the fragments is best obtained by direct 
manipulation, and in fractures of the middle and lower thirds by firm and 
marked ulnar abduction of the hand in a position of semipronation. In 
fractures of the upper and middle thirds, immobilization may be obtained 
by using an anterior right-angle splint which fixes the elbow in right 
angle flexion. It is applied on the flexor surface with the hand supinated, 
that is, with the palm up. In fractures of the lower third the use of an 
anterior and a posterior splint, which keeps the hand in marked ulnar 
abduction are satisfactory if much inward displacement of the upper end 
of the lower fragment is present. This position tends to force the upper 
end of the lower fragment away from the shaft of the radius. It should 
be maintained by applying the two splints with the hand in mid-supination 
to avoid callus bridge occurring. The sling should support the upper and 
middle part of the forearm but not the hand. The splints should extend 
from beyond the elbow to the middle of the metacarpal bones to preclude 
rotation of the hand. This is important. The palmar splint may be 
a right-angle internal lateral one and thus include the lower part of the 
humeral region. The fingers must be free to move. When no displace- 
ment of fragments is present in fractures of the middle or lower thirds 
and in fractures that are incomplete, a palmar splint suitably padded may 
be applied, -extending from the fold of the elbow to the midmetacarpal 
region with the hand supinated. Light massage and passive and active 
movements very moderately employed may be begun at the end of a week 
or earlier. Retentive splints may be removed permanently by the end of 
the fourth week. Gypsum contour splints moulded to the lower part of 
the arm and forearm with the elbow flexed at a right angle and the hand 
in mid-supination are exceedingly serviceable. Aluminum sheets, 3 inches 
wide and 1 / 16 gauge, lightly padded are very satisfactory for anterior 
arid posterior splints. 

When fracture of the upper part of the shaft of the ulna is compli- 
cated by a dislocation of the head of the radius the latter should be 
reduced by traction, countertraction and manipulation first ; then the f rac- 



FBACTURES OF THE BADIUS AND ULNA 411 

ture should be reduced and the parts immobilized on an anterior right- 
angle splint with the forearm in supination. Occasionally exposure of 
the fracture and direct fixation by kangaroo' or chromicized catgut sutures 
are demanded. 

Results. — Union occurs as a rule in three to four weeks. Non-union is 
rare, and union with deformity, if reduction is obtained, is unusual. 

Fractures of the Styloid Process of the Ulna. — It must not be forgot- 
ten that the styloid process arises from the inner and back part of the lower 
end of the ulna. It is separated by a furrow from the head of the ulna. 
These two parts make up the lower extremity of the bone; and as an 
epiphysis unite with the shaft at the twentieth year. The ossific centre 




Fig. 449. — Drawing to show type of displacement in fracture of the shaft of the ulna from direct violence. 

appears at the fourth year. When the forearm and hand are supine the 
part of the ulna felt at the back of the wrist is the styloid process; but 
when the rotating radius carries the hand into a prone position it is felt at 
the palmar surface of the hand; and the ulnar head appears at the back 
of the wrist-joint. This relation of the ulnar styloid must be remembered. 
The styloid process of the radius projects downward from the external 
border of the base of that bone and maintains a constant relation to the 
hand, moving with it in pronation and supination. It is not a slender 
process like the styloid of the radius. 

The ulnar styloid is frequently torn from the shaft of the bone when 
fracture of the carpal end of the radius occurs. It may also be broken 
by direct force applied to it. Pain when the hand is adducted radially, 
local tenderness and crepitus are the symptoms. . The treatment consists 



412 



TEEATISE ON FRACTURES 



in keeping the hand adducted to the ulnar side of the arm and steadying 
the process with an adhesive plaster strap or encasing the wrist in a 
gypsum case. Before the plaster-of-Paris hardens, an indentation made 
by the surgeon on the outside with his thumb will furnish sufficient pres- 
sure to fix the little fragment in position. This procedure is valuable also 
when the fracture occurs with breaks of the base of the radius. Union is 
often fibrous. 

Epiphyseal Separation of the Lower End of the Ulna. — This may occur 



Fig. 450. 



Fig. 451. 





Fig. 450. — Fracture of the head of the radius. No displacement of fragments. 
Fig. 451. — Fracture of the head of the radius, slight displacement of fragment; complicated by frac- 
ture of coronoid process of the ulna. 

between the fourth and twentieth years. Radiograms in which the 
epiphyseal cartilage was seen not yet ossified have been misinterpreted as 
showing a fissure fracture. This fact should be borne in mind. The 
epiphysis includes the styloid process and the head with the articular sur- 
face for the radius. A diastasis here is, however, unusual. The reasons 
given are that the epiphyseal line is convex downwards, the weak spot in 
the. lower part of the ulna is iy 2 inches above the joint and the end of the 
ulna is strongly attached to the radius by ligaments. In addition the 
forces tending to fracture bone in this region are conveyed to the radius 
rather than to the ulna. The ulna takes no real part in the wrist- joint 



FBACTUBES of the badius and ulna 



413 



and is separated from the carpal bones by the triangular interarticu- 
lar fibro-cartilage. 

Detachment of the epiphysis with much displacement would require 
probably local trauma, would give marked deformity, perhaps backward, 
pronation and supination would be limited and painful, and soft crepitus 
likely present. 

It seems as if the lesion would be more likely to occur in association 
with fracture of the shaft of the radius just above its thick base by a 
force carrying the hand suddenly into great radial abduction combined 



Fig. 4- 



Fig. 453. 








Fig. 452. — Fracture of the head of the radius. Moderate displacement of the fragment. 
FlG. 453. — Fracture of the head of the radius complicating posterior luxation of radius and ulna which 

had been reduced. 

with rotation. The treatment is reduction, under anaesthesia, and fixation 
with gypsum contour splints, holding the hand in ulnar abduction, to 
prevent motion between carpus and forearm. A wristlet of adhesive 
plaster would be sufficient in cases with little tendency to recurrence 
of deformity. 

Isolated Fractures of the Radius 

Fractures of the Head of the Radius. — Radiography has shown that 

this formerly supposed rare fracture occurs with comparative frequency. 

Recent literature and a study of a collection of radiographs in hospitals 

will show fracture of the head and neck of the radius to be not unusual. 



414 



TREATISE ON FEACTUKES 



Etiology. — Fracture of the head of the radius may result from various 
injuries. The most common are those from indirect violence, such as 
a fall upon the prone hand with the elbow in full extension, a violent abduc- 
tion of the forearm, and posterior dislocation of both bones of the fore- 
arm in which the radial head indirectly receives part of the force of 

impact, and those due to direct 
violence, such as a blow or a fall 
upon the head of the bone. 

Varieties. — Fractures of the 
head of the radius (Figs. 450-453) 
are intracapsular. The fracture 
may be longitudinal, wedge-shaped, 
or diagonal; the injury may also be 
multiple or impacted. The position 
and form of the fragments are de- 
pendent upon the character of vio- 
lence. Fractures associated with 
dislocation usually show a line of 
fracture involving a portion of the 
upper rim of the head ; those caused 
by violent abduction are situated, as 
a rule, on the outer rim. Fractures 
due to transmitted force through 
the forearm and to falls upon the 
palm of the hand may show a multi- 
ple fracture or the fragment may 
be impacted. Fracture of the 
epiphysis itself or through the 
epiphyseal cartilage is occasion- 
ally seen. 

Displacement. — The fragment 
rarely becomes detached, being held 
by a portion of intact periosteum. 
Impaction of the fragment is often 
seen. It may, however, become dis- 
placed downward, and outward or 
backward, and unite with the neck 
of the radius; it may at times resemble in symptoms a fracture of the 
coronoid process of the ulna. When union of the fragment occurs, if 
it be not impacted, a certain amount of permanent displacement is fre- 
quently present. 

Symptoms. — The most noteworthy symptoms of fracture of the head 
of the radius are pain and tenderness over the region of the head, 
increased by passive pronation and supination of the forearm; impair- 
ment of voluntary pronation, supination, flexion, and extension ; broaden- 




FlG. 454. — Posterior luxation of the radius and of 
the ulna. 



FRACTURES OF THE RADIUS AND ULNA 415 

ing of the head of the radius; and moderate swelling of the elbow-joint. 
Crepitus is present, if the fragment is not impacted ; it is elicited when the 
forearm is pronated and supinated while direct pressure is made with the 
examiner's thumb over the radial head. Displacement of the fragment 
may be at times detected by palpation. Associated injuries, such as dis- 
location of the bones of the forearm, and fracture of the external condyle 
or epicondyle, will be recognized by their usual symptoms. Resort to 
the X-ray is very essential for a proper diagnosis of these fractures, 
and also in the diagnosis of dislocation of the head of the radius 
(Figs. 454-456). 

Treatment. — The form of treatment will depend in a great measure 
upon the radiographic findings. When it is found that the fracture is 
fissured in type, with little or only moderate displacement of the frag- 

Fig. 455. Fig. az$ 




V^ 






yk 



L • -:U .1 £ . : I ,.. ,.. j 

Figs. 455 and 456. — Posterior luxation of the radius and ulna. Untreated case. Patient fell off hay 

wagon three weeks previously. Fig. 455 shows the extent of forced flexion operative reduction. See 

Fig. 454 for rontgenogram. (Courtesy of Dr. Morris Booth Miller.) 

ment, good functional result should be obtained by non-operative methods. 
The same may be said of fractures in which the fragments are impacted. 
Such lesions may be immobilized on an anterior right angular splint from 
mid-humerus to metacarpus with the hand in supination, or on an internal 
angular splint with the hand in pronation for three to four weeks. The 
supine position is probably as a rule the better. After the first week or 
earlier gentle massage should be instituted, and at the end of the third week 
this should be supplemented by passive motion. Gypsum contour splints 
fitting the lower part of the upper arm and the forearm down to the 
middle of the palm are probably the best apparatus for treating fractures 
at the upper end of the radius. Indeed, for most fractures near the elbow 
or wrist, contour splints made of a plastic material are better than wooden 
splints padded to fit the irregularities of the joint surfaces. The former 
fit accurately and will maintain coaptation between small and large frag- 
ments. Wooden splints can only fit well when padded, and the padding 



416 TREATISE ON FRACTURES 

often becomes displaced, or flattened out in the place where it is most 
needed to retain the outline of the broken bone. Dental modelling com- 
pound moulded to fit the region makes a good splint. 

When there is considerable displacement of fragments, and when 
there is marked comminution of the bone, union is likely to occur with 
the formation of considerable callus, which will probably interfere with 
flexion and extension of the elbow, and especially with pronation and 
supination of the radiohumeral joint. Often non-union occurs, and the 
separated fragments then may greatly interfere with the normal motions. 
In these cases the best results will be obtained by arthrotomy for the 
removal of the separated fragments or resection of the broken head of 
the radius. The loss of the radial head, if the neck is not removed and the 




Fig. 457. — Fracture of the upper radial epiphysis. Boy fell over handle 
• of bicycle on palms with arms extended. 

orbicular ligament is left intact, is not a cause of much functional disability. 

Results.— T. T. Thomas reports 18 cases treated conservatively as 
follows: Union without deformity, 3 cases; union with deformity, 5 
cases; non-union, 8 cases; bony ankylosis, 1 case; fibrous ankylosis, 1 
case; and greatly impaired function, 2 cases. Hitzrot reports 19 cases. 
Of these, in 15 instances treated non-operatively there was loss of half 
of rotation in all but 2 cases; of 4 operative cases, in which the fragment 
or part of the head was removed, rotation was better preserved and was 
nearer normal in those in which the entire head was excised. 

Separation of the Upper Radial Epiphysis. — This condition is ex- 
tremely rare. Its presence can scarcely be demonstrated even by the 
radiogram, unless there be marked separation. The centre for this epiphy- 
sis appears as a single centre about the fifth or sixth year, and becomes 
completely ossified about the seventeenth or eighteenth year. 



fbactub.es of the badius and ulna 



417 



Fractures of the Radial Epiphysis. — More common than separation 
of the radial epiphysis is its fracture (Fig. 457). This condition, how- 
ever, is also rare. Fracture usually occurs through the upper portion of 
the epiphysis with the fracture line continuing into the diaphysis. Im- 
paction of the fragments is the rule. The case illustrated is bilateral and 
resulted from a fall over the handle-bars of a bicycle. The boy, who 
was thirteen years of age, fell on both palms with the elbows in full exten- 



Fig. 458. 



Fig. 459. 





/ 




FlG. 458. — Fracture of the neck of the radius with marked displacement of fragments. 
Fig. 459. — Fracture of the neck of the radius. 



sion. Immobilization on an internal right-angle splint for three weeks 
was followed by perfect functional results. 

Fracture of the Neck of the Radius.— Of 23 cases of fracture of the 
head and neck of the radius observed by Plagemann, 4 alone involved the 
neck. Of 18 cases of fracture of the head and neck of the radius studied 
by J. A. Kelly in a collection of radiographs, 9 involved the neck of the 
radius alone. 

Etiology. — Fracture of the neck of the radius (Figs. 458 and 459) 
results from indirect force, like falls upon the palm of the pronated hand 
with the elbow in extension, and forces causing severe abduction of the 
27 



418 



TREATISE ON FRACTURES 



elbow. From the greater frequency with which fractures of the neck are 
associated with posterior dislocation of the ulna or with fracture of that 
bone, it seems probable that the lesion is more often the result of greater 
violence than is fracture of the radial head. Fracture of the coronoid 
process of the ulna is also at times observed in conjunction with fracture 
of the neck of the radius. 

Displacement. — The fracture may be transverse, oblique, or com- 
minuted. Impaction with slight displacement occurs frequently. In other 

instances the fracture is attended with con- 
siderable displacement of the upper fragment, 
mainly characterized by partial rotation out- 
ward and forward. The line of fracture may 
be both intra- and extra-articular. Fracture 
of the head of the radius may also involve the 
neck when the line runs in a ventral direction. 

Symptoms. — In fractures of the neck of the 
radius the most characteristic symptoms are 
marked swelling in the region of the head and 
neck, impairment of pronation, supination, and 
flexion. If the fracture is not impacted, there 
will be noted crepitus at the seat of fracture on 
passive pronation and supination, with failure 
of rotation of the head of the radius. In addi- 
tion there will be localized pain, swelling, ten- 
derness, and in some cases noticeable deformity 
on palpation. In cases the result of severe 
direct violence or wrenching, there may be 
marked swelling of the soft parts with ecchy- 
mosis. A radiograph should be made in sus- 
pected cases. 

Treatment. — The treatment of these cases 
depends upon the line of fracture and the char- 
acter of the displacement of the fragments. In 
impacted fractures with little displacement 
good results may be obtained by immobiliza- 
tion for from three to four weeks upon an anterior right-angle 
splint. Gentle massage should begin at the end of the first week or 
earlier, and be followed by very gentle passive motion at the end of the 
third week. When impaction is not present and but moderate displace- 
ment of the upper fragment has occurred, attempts at reduction should be 
made by manipulation; if reduction is obtained, immobilization as above 
outlined should be the method of procedure. The maintenance of reduc- 
tion should be proved by radiography. If reduction is impossible, or its 
maintenance difficult, or if comminution of the fragments is present, 
arthrotomy and excision of the upper fragment should be performed. 




Fig. 460. — Fracture of the shaft 
of the radius, upper third. 



fbactub.es of the badius and ulna 



419 



Results. — Union occurs as a rule within three or four weeks. Non- 
union is not as frequent as in fractures of the radial head. Hitzrot reports 
ten cases of fracture of the neck of the radius treated by non-operative 
means with loss of about 25 per cent, of rotation. 

Fig. 461a. 



Biceps 




Fig. 461&. 



Brachioradialis 



Pronator 
radii teres" 



Site of fracture • 
Brachioradialis . 



Pronator 
quadratus- 





Fig. 461a. — Fracture of the radius just below the insertion of the pronator radii teres muscle. The upper 

fragment is displaced directly forward in a position midway between pronation and supination. 
FlG. 4616. — Fracture below the middle of the shaft of the ulna, the lower fragment drawn toward the radius 

by the pronator 'quadratus muscle. 

Isolated Fractures of the Shaft of the Radius (Figs. 460-463). — 
Fracture of the shaft of the radius was observed by Plagemann 12 times 
in J3 such radial lesions, while isolated fractures of the shaft of the ulna 



420 



TREATISE O^T FRACTURES 



were observed 15 times in 31 cases of ulna fracture. These statistics as 
to the relative frequency are similar to those generally reported. Of 
these 12 isolated fractures of the shaft of the radius Plagemann gives the 
localization as follows: 2 transverse fractures of the upper third; 3 
oblique fractures at the junction of upper and middle thirds; and 7 frac- 
tures near the junction of the middle and lower thirds. 

Etiology. — Fractures of the shaft of the radius are generally the result 
of direct violence. Indirect violence may occasionally produce the injury; 
especially when the force is applied in a longitudinal direction, as in cases 
reported by Falkson. Muscular action easily produces a fracture. The 
line of fracture is usually oblique, spiral, or irregularly transverse. 



Fig. 462a. 



Fig. 4626. 



Fig. 463. 





Fig. 462a. — Fracture of the shaft of the radius, junction of middle and upper thirds. 
Fig. 462b. — Fracture of the shaft of the radius, middle third. 
Fig. 463. — Fracture of the shaft of the radius, lower third. 

Displacement. — As a rule the displacement of fragments is not great. 
Their position, however, is dependent upon the location of the fracture, its 
variety, and upon the action of the attached muscles, particularly the 
biceps, the pronator teres, and the pronator quadratus. The upper frag- 
ment of the radius in fractures above the insertion of the pronator teres 
is inclined to become supinated by the action of the biceps (Fig. 464) and 
short supinator and pulled upward by the action of the biceps after its 
supinating power has been exerted ; while the lower fragment is pronated 
by the pronator teres and pronator quadratus. This is an indication that 
the hand and forearm should be dressed in supination with the fracture 
apparatus. When the fracture is between the insertion of the biceps and 
that of the pronator, which means below the tubercle and in the shaft for 
two or three inches below that point, the displacement tends to cause 
angulation and rotation toward the shaft of the ulna, due to the pull ex- 
erted by the pronator teres and pronator quadratus at the lower part of 



FBACTUEES OF THE RADIUS AND ULNA 421 

the shaft. This indicates that the fracture should be dressed in mid- 
pronation and maintained in that position. When this fracture is below 
the insertion of the pronator teres, the lower end of the upper fragment 
is apt to be pronated, and the hand may need to be pronated during treat- 
ment. When the fracture is just above the square pronator the lower 
fragment may by spasm be pronated and drawn toward the ulna (Fig. 
465). This condition requires a fracture dressing which will hold the 
hand and radius in mid-supination or full supination. 

Symptoms. — As most of the fractures are the result of direct violence, 
there is generally moderate swelling and ecchymosis of the overlying soft 




Fig. 464. — Drawing to show the effect of the biceps muscle in causing displacement of the upper 
fragment in fracture of the upper third of the shaft. (.Made after rontgenogram, Fig. 460.) 

parts, localized pain, tenderness on pressure, abnormal mobility, deform- 
ity, and crepitus. W r hen the thumb is placed over the head of the radius, 
and passive pronation and supination of the hand made, it will be found 
that the head of the radius fails to rotate unless impaction of the frag- 
ments is present or the fracture is incomplete. In very muscular sub- 
jects the diagnosis may be made with certainty only with the help of 
the radiogram. 

Treatment. — Reduction of fragments may be accomplished by exten- 
sion, counterextension and local manipulation of the fragments. In 
fractures below the middle and in the lower third, when the upper end 
of the lower fragment is markedly inclined toward the ulna, reduction 
may possibly be aided by marked ulnar adduction of the hand in addition 
to traction and countertraction. After reduction the parts should be 
immobilized upon carefully padded anterior and posterior splints, with 



422 TREATISE ON FRACTURES 

the hand in a position midway between pronation and supination, or fully 
supinated according to the situation and character of the displacement. 
In fractures of the upper third or above the insertion of the pronator teres 
muscle, the tendency toward supination of the upper fragment due to the 
pull exerted by the biceps muscle and long supinator should be remem- 
bered ; and in this form the parts should be immobilized upon a right-angle 
anterior splint or moulded gypsum splints with the forearm in full supina- 
tion. Fractures in other parts of the shaft should be put up in mid- 
supination after reduction of the fragments. To prevent pronation 
occurring in these shaft fractures, the splints should have such a bearing 




fe . -"■ .::: , 

Fig. 465. — Drawing to show the action of the pronator quadratus muscle in producing displacement 
of the lower fragment in fracture of the lower third of the radius. (.Made after rontgenogram, Fig. 462ft.) 

on the lower part of the humerus either in front or laterally as will suc- 
cessfully render rotation of the radius at the radio-ulnar joints impossible. 
Immobilization with frequent removal of dressings should be continued 
for three or four weeks. In cases in which satisfactory reduction cannot 
be accomplished or where non-union persists, the seat of fracture should 
be exposed, reduction accomplished, and a direct fixation by plate, 
wire, absorbable lashings, fascial envelopment, or inlaying of bone 
graft adopted. 

Fractures of the Lower End of the Radius. — Fractures of the lower 
end of the radius constitute a large percentage of all fractures. Plage- 
mann's statistics based upon radiographic diagnosis of 1393 cases show 
that there were 38 (2.72 per cent.) cases of fracture of the lower end 
of the radius. Speed, in a review of 10,702 fractures at the Cook County 
Hospital of Chicago, found 533 fractures of the lower end of the radius; 



FBACTUBES OF THE RADIUS AND ULNA 



423 



and 158 fractures of the head and shaft of the radius without associated 
fracture of the ulna. The total number of fractures of the radius was 
826, or J.J per cent., of the ulna 414, or 3.8 per cent. In 19 14 there were 
at the same hospital 54 fractures of the base of the radius of which 15 
were accompanied by fracture of the ulnar styloid process. Fracture 





-' 



Pig. 466. — The base of the radius and the bones of the wrist — 
skiagraph of normal bones, anteroposterior view. (Pilcher.) 



Fig. 467. — Transverse view of the 
normal base of the radius (skia- 
graph). (Pilcher.) 



of the scaphoid bone of the carpus was found in association with one of 
the breaks of the radial base. 

The term Colles's fracture has by unfortunate custom been used for 
a long time to designate all fractures occurring at the lower end of the 
radius. The more closely, however, fractures here are studied the more 



4:24: TREATISE ON FRACTURES 

fully is the fallacy of using the term indiscriminately shown. There are 
so many varieties of fracture at or near the lower end of the radius that 
the term " Colles's fracture," and even that of " classic fracture," should 
be avoided. Many of these cases are clinically similar, and the form of 




Fig. 468a. — Fracture of radius, "about one inch and a half above carpal extremity of the radius," 
with backward displacement — a true Colles's fracture. There is also seen the deformity of the 
base of the radius due to an untreated (?) fracture six months previously, and the accompanying 

fracture of the ulnar styloid. 

treatment is more or less uniform; but the injury Colles of Dublin de- 
scribed is in truth not a fracture of the lower end of the radius at all, 
but occurs in the lower part of the shaft. The term " Colles's fracture " 
should be discarded. 

Etiology. — Fractures of the lower end of the radius may be the result 
of falls upon the palm of the hand in a position of pronation, of falls 



Fig. 4686. — Skiagram showing lateral view of the fracture of the radius about one inch and a half 
above the carpal extremity of the radius. Fig. 468c a true Colles's fracture. 

upon the dorsal surface of the flexed wrist, by direct violence (chauffeur's 
fracture), and by the pull exerted by the anterior or posterior ligaments 
in a position of hyperextension or hyperflexion. In the majority of frac- 
tures of the lower end of the radius it may be generally stated that they 



FEACTURES OF THE RADIUS AND ULNA 425 

are the result of a fall upon the palm of the hand which allows trans- 
mission, through the carpus to the radius, of the force due to the weight 
of the falling body and its velocity. In addition, the pull of the anterior 
carpal ligament in fractures occurring with the hand in a position of 
hyperextension, or the posterior carpal ligament in fractures with the 
hand in a position of hyperrlexion, is a factor in the production of these 
fractures. The agency of the ligamentous attachments is clearly shown 
in the sprain-fractures seen about the wrist-joint. Fractures by direct 
violence are rare, except in the variety known as chauffeurs fracture; this 
injury is produced by the cranking handle of the gasoline engine in back- 
firing striking against the posterior part of the wrist-joint. All injuries 




FlG. 469.— Fracture of lower end of radius with forward displacement one and one-half inches above 
wrist joint. A reversed Colles's fracture, sometimes called Smith's fracture. (Roberts's patient.) 

resulting from this back-firing are not necessarily fractures of the lower 
end of the radius, for fractures involving the carpal and metacarpal bones 
have been thus caused. Sprain-fracture of the radius may result from 
back-firing by throwing the hand into a position of forcible hyperexten- 
sion. In fractures produced by falls upon the hyperextended hand, the 
line of break, its direction, and the degree of displacement of the lower 
fragment depend to a great degree upon the amount of pronation present 
at the time of the fall. In falls forward the degree of pronation is gener- 
ally marked, while in falls to the side or backward the impinging hand 
generally is in a position of marked supination or semi-pronation. 

Varieties. — Study of many radiograms and a small but well-illustrated 
group of pathological specimens has seemed to justify the following- 
division of fractures occurring at the lower end of the radius : 



426 



TEEATISE OX FEACTUEES 



I. Irregular transverse fracture of the radius and ulna (Figs. 472 and 
473). It consists of an irregular, transverse fracture line of both radius 
and ulna, situated from one to one and a half inches above the articular 
surface of the radius. It is mentioned here only on account of the clinical 







Fig. 470. — Old unreduced classic fracture of carpal end of radius, showing characteristic 
backward displacement of carpal fragment. 

resemblance which it bears to the classic fracture of the base of the radius. 
It is most frequently observed during childhood. 

2. Fracture of the styloid process of the radius (Figs. 474a and 475&). 
The following varieties may be recognized : 

(a) Fracture of the tip of the process. 

(b) Fracture of the tip of the process with fracture of the shaft 
of the ulna. 

(r) Fracture of the base of the process with fracture of the scaphoid. 
This fracture is relatively rare. It is the result of a fall upon the hand in 



^§5 




Fig. 471. — Old unreduced classic fracture of carpal end of radius, showing characteristic 
backward displacement and not the unusual fracture of the ulnar styloid process. 

a position of full pronation. It may be associated with fracture of the 
carpal bones, particularly the scaphoid. Infrequent forms of fracture 
of the radial styloid are those resulting from muscular pull with the hand 
in forced hyperflexion seen in the infrequent sprain-fractures. 



FEACTUEES OF THE EADIUS AND ULNA 



427 



Fig. 472. 











Fig. 473. 



Fig. 472. — Low transverse fracture of radius and ulna. Clinical resemblance to Colles's 

fracture. 
Fig. 473. — Low transverse fracture of radius and ulna. Marked displacement ot lower 

fragments. 



428 



TREATISE OX FRACTURES 

Fig. 474a. Pig. 474&. 




Fig. 475a. 



Fig. 475b. 



Fig. 474a. — Fracture of the tip of the styloid process of the radius. 

Fig. 474b. — Fracture of the base of the styloid process of the radius. 

Fig. 475a- — Fracture of the base of the styloid of the radius and of the styloid of the ulna. 

Fig. 475^- — Separation of lower epiphysis of radius with fracture of outer part of the diaphy- 

sis, resembling in a great degree fracture of the styloid process. 



FRACTURES OF THE RADIUS AND ULNA 



429 



3. Irregular transverse fracture about one-half inch above the articu- 
lar surface of the radius, with posterior and at times outward (radial) 
displacement of the lower fragment (Figs. 476-484). It is often im- 
properly called Colles's fracture of the radius. The fracture which Colles 





i 



Fig. 476. — Irregular transverse fracture of lower end of radius. Type of Colles's fracture 
Note that external view shows usual rotation backward of lower fragment. 

described had its fracture line ^4 to 1 inch further from the radio-carpal 
joint. The line in this transverse and very common break varies within 
certain limits, but it is generally near the point where the cancellous bone 
of the base is rapidly replaced by compact bone. It has been supposed 




Fig. 47 7. — Dissection of fracture of the base of radius with forward displacement — union without reduction. 

(Museum of New York Hospital.) 

that the plane of the fracture surface was obliquely upward and back- 
ward; but obliquity of direction of the fracture is not characteristic, nor 
is the exact distance of the line above the articular surface. The prin- 
cipal characteristics of this well-known fracture are an isolated fracture 
of the lower end of the radius, with the fracture line generally transverse, 



430 



TREATISE OX FRACTURES 






Fig. 478. — X-ray of fracture with anterior displacement of 

lower fragment, union without reduction showing increase of 

concavity of radial arch. 




Fig. 479. — Edinburgh specimen of united, but unreduced, 

fracture of radius, with anterior displacement of carpal 

piece. 



about three-eighths to three- 
fourths of an inch above its 
distal extremity, with pos- 
terior and at times outward 
(radial) displacement of the 
lower fragment. Impaction 
of the fragment is often 
present, as is also outward 
displacement of the wrist, 
and rotation posteriorly of 
the articular surface of the 
lower end of the radius. 
The varying types of this 
" classic " fracture may be 
described thus : 

(a) Those of adult life. 

(b) Those of childhood. 

(c) Associated with 
fracture of the styloid proc- 
ess of the ulna. 

(d) Associated with 
comminution of the lower 
fragment. 

(e) Associated with frac- 
ture of the neck of the ulna, 

4. Irregular 
transverse fracture 
with anterior dis- 
placement of the 
carpal fragment ; 
sometimes improperly called 
reversed Colles's fracture. It 
was really described early by 
R. W. Smith. It is situated 
near the wrist- joint and not 
at the place of the fracture 
described by Colles. It is a 
reversed displacement of the 
fracture here discussed under 
the third variety of fractures 
of the base of the radius. It 
is sometimes called Smith's 
fracture (Figs. 485 and 
486). At times the line of 



FBACTUBES OF THE BADIUS AND ULNA 



431 



fracture runs obliquely upward and forward. This lesion was first recog- 
nized by Smith, and later Roberts collected 24 cases and 31 specimens. 

5. Separation of the radial epiphysis (Figs. 487-490). 

(a) With fracture of the diaphysis. 

(&) With fracture of the anterior edge of the diaphysis. 

(c) With fracture of the posterior edge of the diaphysis and accom- 
panying separation of the ulnar epiphysis. 

Isolated separations of the radial epiphysis are very rarely seen. It is 




Pig. 480. — Transverse fracture of the lower end of the radius with 

impaction of fragments and posterior displacement of the lower 

fragment. 

doubtful if a pure epiphyseal separation ever occurs, excepting in very 
young children. The usual lesion consists in an accompanying fracture 
of either the posterior or anterior edge of the diaphysis, plus the separa- 
tion of the epiphysis. The periosteum remains intact on the side opposite 
to the detached fragments. The lesion closely resembles the classic 
fracture at the lower end of the radius, except for the absence of impac- 
tion, outward displacement, and loss of shortening of the distance 
between the radial styloid and the upper end of the bone. 



432 



TREATISE ON FRACTURES 




Fig. 481. — Transverse fracture of the lower end of the radius with outward and posterior 

displacement of the lower fragment. This type gives the abduction and "silver-fork" 

deformity typical of many fractures of the base of the radius. 





Fig. 482. — Old united fracture of radial base with ununited fracture of the styloid process 

of the ulna. Note abduction and posterior displacement of lower part of radius. This 

fracture was never properly reduced. 



FRACTURES OF THE RADIUS AND ULNA 

A B 



433 




Fig. 483. — Atypical type of fracture of lower end of radius. Note comminution of frag- 
ments. Not a typical form of fracture at radial base. 




FlG. 484. — Healed fracture of lower end of radius. Note posterior displacement and 
rotation of the lower fragment. Typical form of unreduced fracture in old people. 




Fig. 485. — Type of so-called reversed fracture. Note the anterior displacement of the lower fragment, 
which is shown well on lateral view, and the dorsal ulnar projection. 

28 



434 



TEEATISE ON FRACTURES 




X 





Fig. 486. — Fracture of the lower end of the radius with anterior displacement of the carpal fragment. 
Note that the radial arch on the flexor surface is markedly increased. (The so-called Smith's fracture.) 



Fig. 487. 



Fig. 






Fig. 487. — Separation of lower radial epiphysis with posterior displacement of epiphysis, and a small 

fragment of the diaphysis. 
Fig. 488. — Separation of lower radial epiphysis and fracture of the anterior portion of the lower edge 
of the diaphysis, with anterior displacement of the lower fragment. 



6. Fractures through the carpal articular surface with separation of 
the posterior articular edge. This is the true but unusual Barton's frac- 
ture (Figs, 491 and 492). This fracture may have associated with it a 
fracture of the ulnar styloid, or a fracture of the internal articular edge 
as well. Such injuries are usually the result of direct violence. 



FRACTURES OF THE RADIUS AND ULNA 



435 



7. Fractures through the carpal articular surface with separation of 
the anterior articular edge. This may be designated reversed Barton's 
fracture (Fig. 493). They may be the result of direct violence or be 
produced by forcible hyperflexion, in which instances they may be well 
termed sprain-fractures. 

8. Green-stick fractures (Figs. 496 and 497). Several varieties of 
green-stick fractures occur : 

(a) Involving the entire thickness of the bone. 





A B 

Fig. 489. — Separation of lower radial epiphysis with posterior displacement of the lower fragment. 



(b) Involving only a portion of the cortex (cortex or infolding 
fractures). 

(c) Involving the entire thickness of the shaft accompanied by a 
fracture of the ulnar styloid or shaft. 

(d) A form of cortex fracture which is only recognizable after four 
to five weeks have elapsed, when it will be noticed by a deposit of cancel- 
lous tissue along the course of previously detached periosteum. In this 
form of fracture there is no appreciable bony lesion discoverable with 
the radiogram at the time of the injury. 



436 



TREATISE OX FRACTURES 





Fig. 490. — Separation of the lower radial epiphysis with outward and posterior displacement of the 

epiphysis. 



Fig. 491. 



Fig. 492. 




Fig. 491. — Fracture through the carpal articular surface with separation of the posterior articular 

edge (.Barton's fracture). 
Fig. 492. — Fracture through the carpal articular surface with separation of the posterior articular 

edge. 



FEACTUBES OF THE BADIUS AND ULNA 437 

Of particular interest is the infolding fracture (b). It is observed 
in children between the ages of seven and fourteen. The lesion consists 
of bending outward of the cortex and occurs where the resistant cortex 
meets the flexible cortex. The position of this fracture varies with the 
age of the child. The younger it is the nearer is the line of fracture to 
the epiphysis. In childhood the cortex is still flexible, and as a result 
of impaction and slight flexion the cortex bulges outward. 

9. Longitudinal fissure fracture (Figs. 498a and 499O. Irregular 
longitudinal Assuring may be ob- 
served, without transverse frac- 
ture, with transverse fracture, 

and with oblique fracture. Longi- 
tudinal fractures are unusual and 
generally the result of transmitted 
force directed upward through 
the hyperflexed palm and carpal 
bones. A rare form is double 
longitudinal lines united by a 
transverse line resembling the 
Greek letter y. 

10. Isolated oblique fracture * 1 
running downward and outward # ^^1 
(Fig. 500). This lesion may 

have associated with it comminu- 
tion and Assuring of the upper 
fragment. k 

11. Isolated oblique fracture 
running downward and inward 
(Figs. 501a and 501&). . 

12. Transverse Assuring or 
incomplete fracture without dis- 
placement in the adult. 

13. Sprain-fractures (Figs. I^HHl 

c;02(7 ^02/?^ A varietv of lesions FlG - 493-— Fracture through the carpal articular 

U ^«, yV^VJ- ^ Vdlieiy Ol ICS.lUIlb surface with separation of the anterior articular edge. 

may be Classified Under this term. (Reversed Barton's fracture.) 

These fractures are the result of rapid, forcible hyperflexion, hyper exten- 
sion, or hyperadduction. The lesion consists of the detachment of par- 
ticles of cortex at the point of attachment of ligaments forcibly stretched. 

14. Chauffeur's fracture (Figs. 503-505). Under this term are classi- 
fied those fractures received while cranking a gasoline motor, when back- 
firing occurs. They are the result of direct violence from the starting 
handle hitting the back of the hand or forearm, or are due to forcible 
hyperextension. They differ in character, depending upon the mode of 
production. When due to direct violence, a transverse fracture usually 
results. When due to forcible hyperextension, the fracture partakes of the 



438 



TREATISE OX FRACTURES 



nature of a sprain-fracture. The location of the lesion depends upon the 
part struck when due to direct violence and may involve the radius alone, 
the radius and ulna, the carpal bones, or the metacarpals. When due 
to hyperextension the lesion usually involves the anterior articular edge 
or the styloid process. 



Radial 
Styloid 




u/nar. ftadia/ 
Sty/cud Styloid 




Sfi/lQJtf 



Fig. 494. — Outlines of hand placed with palm on table, showing change of 

relation of styloid processes caused by classic fracture of lower end of radius. 

Curved line indicates joint. 

The above classification of fractures occurring at the lower end of the 
radius is sufficiently comprehensive to cover practically all forms in 
this region. 

Symptoms. — It may be stated that unnecessary roughness is often 

Forearm 

Hand 



€V % 



CI* Diagram of Deformity in fracture with forward Displace/nenf 

(Gardener's spade) 

Forearm ^^^ H*n<t 

b. Diagram of Deformity in fracture witH Backward Disvlacemenr 

(Silver fork) 

Pig. 495. — The lines show the difference in the planes of the dorsum of forearm, wrist, and hand in the 
classic fracture of the radial base (silver -fork deformity) (&) and in the reversed, or forward displacement 
of the carpal fragment (gardener's spade deformity) (c). 

used in endeavoring to make a diagnosis of fracture at the lower end 
of the radius. The necessity of pain-giving manipulation may be limited 
in the majority of cases by careful observation of the part and comparison 
with the other forearm. Crepitus is a symptom which is often absent 



FBACTUEES OF THE RADIUS AND ULNA 



439 






X 



Fig. 496. — Incomplete (.green-stick) fracture of the lower end of the radius. Typical cortex 
or infolding fracture. Entire thickness of bone is not involved. 



: ' ; ^t» 




Pig. 497. — Incomplete (.green-stick) fracture of the lower end of the radius with fracture of 

the styloid of the ulna. 



uo 



TREATISE ON FRACTURES 

Fig. 498a. Fig. 498ft. 



y 



N 



\ 








Figs. 498a and 498ft. — Types of longitudinal fissure fracture of the lower end of the radius. 
Fig. 499a. Fig. 499ft. Fig. 499c 





Figs. 499a, 499ft, and 499c. — Types of longitudinal fissure fractures of the lower end of the radius. 



FRACTURES OF THE RADIUS AND ULNA 



441 



and it causes only pain to the patient to endeavor to demonstrate its 
presence. Many of these fractures are impacted and some comminuted, 
and crepitus is not demonstrable without undue force. In the classic 
fracture, when severe, inspection will soon show general swelling about 
the wrist- joint and even extending several inches above it. On the flexor 
surface there will be loss of the normal radial arch, and on the extensor 
surface swelling over the upper end of the lower fragment extending 
downward for a variable distance, presenting from a lateral position the 




/ 




Fig. soo. — Isolated oblique fracture of the lower end. of the radius with the line of fracture running 

downward and outward. 

so-called " silver-fork " deformity (Fig. 506). When the backward dis- 
placement is marked, the dorsal edge of the lower fragment can be felt 
as a ridge about half an inch above the wrist-joint. This is best done 
by running a finger of the surgeon down the posterior surface of the 
radius. In addition to this deformity, there is generally abduction of the 
hand and broadening of the wrist (Figs. 507a and 508). Palpation of 
the parts shows loss of the radial arch at its lower flexor region and at 
times prominence of the lower end of the upper fragment on the flexor 
surface. Prominence of the lower fragment occurs posteriorly with rota- 



442 



TREATISE OX FRACTURES 



tion of the same backward, so that the transverse plane of the articular 
surface of the lower end o>f the radius is rotated from ten to thirty degrees. 
Posteriorly there is a loss of prominence of the styloid process of the 
ulna, with a corresponding prominence of the same on the flexor surface 
of the wrist, so that it is brought into a closer relation with the pisiform 
bone. Comparison of the radial styloid with that of the ulna will show 
that it is carried toward the elbow and is therefore on a line with, or a 

Fig. 501C. 








Fig. 501b, 




V 






V* 




J hT^ 


\j 


IIS- 




n 









Fig. 501a. — Isolated oblique fracture of the lower end of the radius with the line of fracture running 

downward and inward. 

Fig. 501b.— Isolated oblique fracture of the lower end of the radius with the line of fracture running 

downward and inward; also a fracture of the lower third of the ulna. 



little above, the ulnar styloid. Normally it occupies a lower plane (Fig. 
509). In many cases there is not only a posterior rotation and displace- 
ment of the lower fragment, but also an external or radial abduction of 
the carpus and fingers. The hand and fingers are held in semiflexion and 
full flexion is possible to a less degree relatively than full extension. 

Impaction of fragments is present in many instances, so that crepitus 
and abnormal mobility are not readily determined. The swelling noticed 
in all fractures of the lower end of the radius may at times be augmented 
by an effusion of serum within the tendon sheaths, the presence of hemor- 



FRACTURES OF THE RADIUS AND ULNA 



443 



rhage outside the sheaths, and effusion within the wrist-joint. The line 
of the radiocarpal joint is a curve with convexity upward toward the 
elbow in the normal condition. Pressure here will often differentiate a 
mere sprain or rheumatic arthritis from fracture above the joint 1 , because 
the tenderness elicited will be over the curved joint line instead of over 
the base of the radius. 

In the non-classic fractures of the lower end of the radius the symp- 
toms above described will be wholly or in part absent, and when present 



Fig. 502a. 



Fig. 502&. 




Figs. 502a and 5026. — -Types of sprain fractures of the lower end of the radius and in carpus. 

may show specific differences. Many of these fractures are unaccom- 
panied by deformity or crepitus, the most noticeable symptoms being 
localized swelling and localized tenderness on pressure. This occurs when 
there is little displacement and little laceration of periosteum. In some 
cases, notably the transverse fractures with impaction and little deformity, 
the infolding fractures and the sprain-fractures, there may be bony lesions 
discoverable only by their radiogram. Fractures of the scaphoid bone 
may be unrecognizable except by examination of rontgenograms. Such 
fractures may simulate fracture of the posterior edge of the radius at 
its articular surface. 



444 



TREATISE OX EBACTUKES 





Fig. 503. — Chauffeur's fracture. Line of fracture is at base of styloid process. No displace- 
ment of fragments. 



Fig. 504. 



Fig. 505. 




A B 

Fig. 504. — Chauffeur's fracture. Line of fracture is transverse at lower end of radius, also involves 

styloid of radius; also a fracture of styloid of ulna. 

Fig. 505. — Chauffeur's fracture by muscular action; a small portion of bone is torn out of outer part 

of radius at base of styloid process. 



FRACTURES OF THE RADIUS AND ULNA 



445 



In injuries about the wrist- joint, lateral and anteroposterior radio- 
grams should be taken, if practicable, in all cases of doubtful diagnosis, 
and also when it is necessary to determine the degree of replacement of 
the fragments after reduction. 

Diagnosis. — The diagnosis of fractures at the lower end of the radius 
is to be made by careful inspection, and palpation and the radiogram. 




Fig. 506. — Photograph of unreduced classic fracture, 7 weeks old. Note the so-called "silver-fork" 

deformity. 
Fig. 507. Fig. 508. 



; • '■.■■;'■' 



■t~~l 



F^^'i ' 



f 



r 





. . 



Figs. 507 and 508. — Old fracture of radius and of styloid process of ulna with rupture of radio-ulnar 

ligaments. Note broadening of wrist, abduction deformity and prominence of styloid process of ulna. 

(Courtesy of Dr. John H. Jopson.) 

Deformity when present is usually typical. The most striking changes 
are absence of the radial arch, broadening at the wrist, rotation, and at 
times displacement of the lower fragment posteriorly, combined with 
localized swelling. There is generally effusion into the tendon sheaths. 
Lateral displacement of the hand, the so-called bayonet deformity, is 
frequently present, particularly in people of advanced life, with comminu- 
tion of the lower fragment. In doubtful cases the diagnosis may always 
be made by the use of the radiogram. 



446 



TREATISE OX FRACTURES 



The ridge caused by the upper border of the lower fragment usually 
may be felt with the tip of the ringer about a half inch above the wrist- 
joint. The line of the joint is a curved line, convex upward, running 




Fig. 



500. — Drawing to show deformity which may occur in fracture of the lower end of radius and 
ulna. Note posterior displacement of both lower fragments. 




Fig. 510. — Method of palpation to determine the relative positions of the styloid processes of the 
radius and of the ulna. Normally that of the radius occupies a lower plane than that of the ulna. 



FRACTURES OF THE EADIUS AND ULNA 



U7 



-a 




-• cs 



3t? £ 



1$ 



<!*. 3 









US TEEATISE OX FRACTURES 

from radial styloid to the lower end of the ulnar styloid with the patient's 
hand pronated. Recollect that the ulnar styloid is toward the palmar 
surface of the ulnar border of the wrist. When there is much displace- 
ment radially the edge of the fragment may be felt as a ridge on the radial 
border above the wrist. 

Differential Diagnosis (Fig. 510). — Conditions that may be confused 
with the usual so-called classic fracture are backward and forward luxa- 
tion at the radiocarpal articulation, mediocarpal luxation backward and 
chipping off at the posterior edge of the radius at the radiocarpal joint and 
of the anterior edge of the radius at that articulation. The important 
question is to recognize that a fracture and not a mere sprain exists ; and 
that the lower end of the radius is deformed by displacement of the distal 
fragment or fragments. Recollection of the normal arch of the palmar 
surface of the lower fifth of the radius, of the relative positions of the 
styloid processes of the radius and ulna, and of the convexity obliquely 
upward of the line of the radiocarpal joint between these two land- 
marks will usually avert erroneous diagnosis. The surgeon has the well 




Fig. 512. — Note posterior displacement of lower fragment without 

impaction; stripped up periosteum still forms a band uniting the upper 

and lower fragments and holding them in their new relations. 

arm of the patient for a control, unless it has been previously subjected 
to deformity from injury. The exact line of break is of no great im- 
portance ; but the surgeon must reconstruct the normal contours of the 
bone at once and provide efficient support, not restraining very much 
the movements of the fingers by the splint employed. Cotton lays stress 
on the importance in typical fractures of the loss of the normal promi- 
nence of the head of the ulna on the back of the wrist in diagnosis of the 
backward displacement of the carpal fragment of the radius. The hand 
in this usual type of fracture is generally held in partial flexion but is 
not entirely disabled. Its usefulness as to mobility of fingers is liable 
to give rise to the opinion that no fracture exists. The swelling from 
effusion and bleeding into the soft parts often conceals the bony distor- 
tion. A lateral view gives the so-called " silver-fork " appearance. 

In transverse fracture with forward displacement of the carpal frag- 
ment, the so-called " gardener's spade " deformity occurs. This fracture 
is rather rare but is often unrecognized. 

In fractures here the radiogram is of invaluable assistance in arriving 
at a correct diagnosis. Cotton very wisely says that, although the X-ray 



FRACTURES OF THE RADIUS AND ULNA 



449 



examination is very useful in showing the existence of fracture and the 
amount of displacement, if two plates are taken in planes at a right angle, 
the reduction need not be delayed while waiting for its employ for 
diagnostic purposes. Except in cases of no, or very little, displacement, 
experience will show the trained observer that reduction is needed. The 
radiograph may be needed to decide doubtful cases of subperiosteal frac- 
ture, fracture with unusual lines, and may disclose incompleteness of the 
efforts of reduction already made. Careful comparative study of the 
anatomical relations of the two wrists will aid much. The test to dis- 
criminate between radiocarpal arthritis and fracture, by pressure over the 
joint line, has been mentioned. Fracture without displacement will be 
made evident by tenderness on pressure and will perhaps show within a 
few days a localized ridge of callus. It must be remembered that the 
uninjured wrist may be somewhat deformed by previous fracture forgot- 




Fig. s 13. — Method of reducing the lower fragment when displaced backward. The surgeon's 
thumb on the lower fragment forces it down into normal position at the moment he flexes the 

patient's wrist. 



ten by the patient. Recently such an instance occurred in the practice of 
one of the authors. The woman denied the receipt of any injury of the 
opposite arm, but the suspicion of the surgeon was confirmed by 
X-ray study. 

Treatment. — In the treatment of fracture at the lower end of the 
radius it is well to have a clear conception of the exact nature of the 
fracture before reduction is attempted. In the usual or classic fracture, 
without complicating lesions, however, reduction usually may be per- 
formed satisfactorily without a primary radiogram. This statement 
applies particularly to the typical transverse fracture with backward dis- 
placement of the lower fragment. The most important task in the treat- 
ment of typical fractures at the lower end of the radius with posterior 
displacement of the basal fragment is to obtain complete reduction as 
soon as seen, if practicable. To retain the fragments in their proper 
position after reduction, until union has occurred, is not very difficult. 
29 



450 



TREATISE OX FRACTURES 



The vital mistake often made is in not obtaining complete reduction. In 
many instances this will be secured only with the help of an anaesthetic, 
because the pain of forcible reduction is great. Primary anaesthesia with 
ether or momentary unconsciousness from nitrous oxide gas is all that 
is necessary. Bad results following this fracture are usually attributable 
to the surgeon's failure to secure reduction and not to faulty methods 
of immobilization. 

If the fragments are thoroughly reduced, the tendency to recurrence 
of the deformity is slight except when the lower fragment is much 
comminuted or the complicating fracture of the ulnar styloid or head 
permits displacement. The usual backward deformity is not due to mus- 
cular contraction but to the force of the injury, causing interlocking or 




Fig. 514. — Method of reducing the carpal fragment, displaced backward, by first breaking up 
the impaction by means of hyperextension across the operator's knee. The loosened fragment is 
then forced into place, by the right thumb during flexion of the wrist, to reconstruct the normal 
arch on the palmar aspect of the lower fifth of the radius. The same manipulations are used in 
correcting old unreduced fractures to rupture the unioning callus and set the fragments. 

impaction of the fragments. After thorough reduction, the simplest 
form of retention will suffice in most cases, provided that the arch of the 
lower fifth of the radius on its flexor surface is thoroughly reconstructed. 
The existence of this arch-like contour in the normal radius is often for- 
gotten. There are many methods of reduction which may be used in the 
reduction of fractures of the base of the radius. In many fractures here, 
notably the sprain-fractures, comminuted fractures, and fractures of the 
radial styloid, reduction is accomplished with little effort and without 
anaesthesia. It is, however, in the most frequent typical and nearly trans- 
verse fracture that considerable effort at reduction is necessary. Firm 
impaction is present in a large number of instances. No one method 
of reduction is applicable to all cases. 

Frequently reduction may be accomplished by firmly seizing the fore- 
arm, with one hand at the junction of its middle and lower thirds for 



FRACTUKES OF THE KADIUS AND ULNA 



451 



countertraction, and making traction by grasping the wrist of the patient 
with the other hand, which should encircle his wrist-joint, with the thumb 
pressing upon the backwardly displaced lower fragment. The fragments 
should be disengaged by traction and countertraction, aided perhaps by 
first increasing the deformity by forcible dorsal extension at the seat of 
the fracture. Strong pressure with the operator's thumb at the moment 
he makes strong and sudden flexion of the wrist and lower fragment of 




Fig. 5.15a- — Moulded dorsal gypsum and gauze splint used after 

reduction of backward displacement of fracture of base of radius. 

Splint is seen through bandage. 

the radius will then drive the lower fragment down into place. After 
the fragments have been disengaged, if interlocked or impacted, marked 
flexion at seat of fracture is to be suddenly made, combined with ulnar 
adduction. This latter procedure will correct posterior displacement of 




Fig. 515&. — Gypsum gauze encasement used for a fracture of lower end of radius with the 
usual backward displacement, after fragments have been reduced. 

the lower fragment, reestablish the radial arch, and overcome the abducted 
position of the lower fragment, which is so frequently present in the 
typical injury (Figs. 516-518). 

After the radial arch has been corrected, the undue prominence of 
the ulnar styloid changed, and rotation and adduction of the lower frag- 
ment accomplished, one may be reasonably sure of obtaining a good result 
if the corrected position of the lower fragment is maintained until union 
has occurred. 



452 



TREATISE OX FRACTURES 




Fig. 516. — Method of breaking of impaction of classic fracture at the lower end of the radius 
by increasing the deformity. 




Fig. 517. — Method of reduction of classic fracture at the lower end of the radius by forcible 
carrying forward of the lower fragment, with adduction of the hand. 





Fig. 518. — Morton's method of reducing the fracture by sudden snapping of the lower 
fragment forward. The thumbs are placed on the posterior surface of the lower fragment, the 
interlocked fingers of both hands on the anterior surface of the lower end of the upper fragment, 
and by a sudden snapping motion the lower fragment is carried forward with the hand of the 

patient. 

Maintenance of reduction may be accomplished by the use of any of 
several forms of dressing. A gypsum splint moulded to fit the dorsal or 
the flexor surface when the wrist is somewhat flexed cannot be improved 
upon. In reduced fractures with little tendency to displacement, a slightly 



FBACTUBES OF THE BADIUS AND ULXA 



453 



padded, narrow wooden splint applied to the dorsal surface of the fore- 
arm and hand, extending from a few inches below the elbow to a point 




j 



Fig. 518a. — Fracture of lower end of both radii treated by forced reduction, and 

replacement maintained by keeping wrist flexed with dorsal gypsum splint moulded to 

forearm and hand. Patient had both radii broken by fall down stairs. 







Fig. 519a. 






1 


^■H^hP 






"I 












'■"^ 












-. 





Fig. 5196. 





Figs. 519a and 5196. — Show application of posterior padded straight splint for immobilization of 
fracture at the lower end of the radius when there is no tendency toward recurrence of the deformity. 

just above the metacarpophalangeal joints, will steady the fragments and 
be all that is necessary (Figs. 519a and 519&). This is due to the circum- 
stance that the dorsum of the reconstructed radius is practically level 



454 



TEEATISE ON FRACTURES 



(Fig. 520). This is not the case with the flexor surface of the radius, 
which is arched in its lower fifth. If a wooden splint is placed on the 
palmar surface, it must be covered with sheet-wadding and have a hard 
pad placed at its lower end to fill the normal radial arch. It should in 
many cases be supplemented by a posterior splint. The splints may be 
attached to the forearm and hand by thick strips of adhesive plaster one 
and one-half inches in width, the upper strip at the upper level of the splint, 
the second strip over the lower fragment, and the third strip, about one- 
half inch in width, should be applied to the lower end of the splint and 
hand (Fig. 521). Over the splint, forearm, and hand a snugly-fitting 




J 



Fig. 520. — Demonstrating the plane of the posterior aspect of the bones of the forearm and hand. 








Fig. 521. — Method of application of anterior and posterior padded splints for fracture at the lower 
end of the radius. Note supplementary pad to retain radial arch. 

muslin bandage two inches in width should be applied and the part put at 
rest in a comfortably fitting sling. This is the dressing preferred by 
Doctor Kelly and Doctor Scudder; and similar ones are used by Doctor 
Cotton and others. Doctor Roberts does not like it, but prefers the 
wrist flexed with the hand pronated and a dorsal moulded gypsum splint 
used, for maintaining the coaptation of fragments after reduction of the 
displacement with correction of the rotation and the ulnar adduction of 
the carpal fragment. 

In fractures in which there is marked tendency to repeated displace- 
ment of the fragments, anterior and posterior splints of basswood are 
applied by some. They should be of the same length as described above. 
Both splints should be pistol-shape, so as to maintain adduction of the 
lower fragment and hand. They are best described by the accompanying 



FKACTUKES OF THE RADIUS AND ULNA 

Fig. 522a. 



. 



455 





Figs. 522a, 5226 and 522c. — Method of application of the anterior and posterior padded abduction 
splint. This form of splint is useful in maintaining reduction of fragments when there is a tendency 

toward adduction deformity. 

illustrations. The two splints should be carefully padded with four to six 
layers of sheet-wadding and, in addition, a pad of sheet-wadding should 
be placed on the flexor surface of the forearm to maintain the lower end 
of the upper fragment in its proper position and retain the normal radial 
arch (Figs. $22a-$22c). A splint half the length and half the width 



456 TREATISE OX FRACTURES 

of that shown is preferred by one of the authors. He prefers also the 
wrist flexed as shown in the figure of the dorsal gypsum moulded splint. 
If reduction is complete and the wrist kept flexed, the extensor tendons 
will hold the lower fragment in place nearly always. A pad may be 
at times placed over the posterior portion of the lower fragment, but great 
care should be used in its application, as pressure sores, especially over 
the bases of the second and third metacarpal bones, are prone to develop 
if the dressing is at all tight. In many instances this pad is unnecessary. 
It is well to remember that in fractures, pressure from pads for the pur- 
pose of reducing deformity is dangerous. The splints should be held to 
the forearm and hand with three strips of adhesive plaster, as shown in 
the illustration, and over all a snugly-fitting muslin bandage should be 
applied. The forearm should be carried in a sling until union is firm. The 
use of strips of adhesive plaster around limbs to hold splints in position 
is fraught with danger, except in skilled hands. Inflammatory swelling 
may unexpectedly occur, and cause injurious constriction. The use of 
a primary bandage next to the skin, used by some surgeons in the treat- 
ment of fractures before applying splints, is a source of danger from 
constriction becoming great should swelling be rapid and the dressing 
be not quickly removed. The habit of holding splints in position by 
encircling strips of adhesive plaster is therefore not utilized with safety 
by inexperienced dressers of recent fractures. Pads to hold fragments 
in place by pressure are also dangerous. The splint would better be 
moulded to exactly fit the contour of the limb and bones after the reduc- 
tion of the surgeon's hands has reconstructed the skeleton. Hence the 
great value of plastic contour splints. 

The treatment of these cases is well conducted with moulded contour 
splints of plaster-of-Paris. A plaster bandage should not be applied in 
a circular manner until swelling has subsided; but a posterior splint 
made of gauze and gypsum should be moulded to the reconstructed 
forearm and hand, properly padded with a thin layer of sheet- 
wadding and applied to the part. The splints should be held in place 
with a gauze bandage. Whatever dressing is adopted, reduction of the 
fragments must first be secured, and in all cases the fingers should be 
allowed opportunity for active movements from the very beginning 
of treatment. 

As has been said above, splints may be applied with the hand in a 
position of semi-pronation or pronation, though even supination is not 
objectionable. Every fracture should be inspected not later than twenty- 
four hours after the application of the splint; the bandage should be 
removed and the parts examined for areas of undue pressure, and the 
splint or splints reapplied. The surgeon should always remove the splints 
immediately and examine the parts if there is any evidence of undue swell- 
ing or cyanosis of the fingers. This precaution should be taken for pain, 
numbness, paresthesia, and for localized pain in the region of the lower 



FEACTUEES OF THE EADIUS AND ULNA 



457 



fragment or the bases of the second and third metacarpals posteriorly. 
If a moulded metal (Figs. 523^7 and 523^) or gypsum splint is used on the 
palmar aspect of the forearm, it should extend as far as the middle of the 
palm, and the wrist should be partially flexed. 

The line of treatment here indicated is that to be used in practically 
all recent fractures of the lower end, or base, of the radius. When the 
ulnar styloid is broken from its shaft, as a complication of the break 
of the radius, it is well to deflect the hand a little toward the ulnar 
border of the forearm by the retentive dressing. A small pad against 
the broken process or a " thumb dent " in the gypsum splint may aid in 

Fig. 523a. 




Fig. 523b. 




Figs. 523a and 5236- — Use of the Levis's metal splint in the treatment of fractures at the lower 

end of the radius. 

holding the little fragment in place. Union is apt to be fibrous, prob- 
ably because it usually is not kept in contact with the shaft. This defect 
is not very important. 

After-treatment. — The dressing should be inspected every one or two 
days for the first week, and every third day during the second week. 
If the radiogram shows that reduction is faulty, further reduction should 
be accomplished. At every dressing the splint should be removed, the 
arm bathed, and moderate massage and passive motion of the wrist-joint 
performed by the surgeon. At the end of the second week the posterior 
splint may be discarded if two splints have been employed. At the end 



458 TEEATISE OX FRACTURES 

of three or four weeks all may be removed. An adhesive plaster cuff two 
inches wide may be used for slight protection for a week or two longer. 
Some patients who are careful or are not exposed to strain upon the fore- 
arm and hand will not require such a long period of restraint. Some cases 
will need very little dressing, except an adhesive plaster cuff, from 
the beginning. 

Treatment of Basal Fracture with Anterior Displacement of 

the Carpal Fragment 

The more or less transverse fracture about a half inch above the 
radiocarpal joint, with displacement of the lower fragment forward, is 
often called Smith's fracture, or reversed " classic " fracture. It produces 
a deformity resembling the planes of a gardener's spade instead of the 
silver-fork deformity of the typical transverse fracture in the same por- 
tion of the radial base. 

Its treatment should be conducted on the same principles as the typical 
or so-called classic fracture, which is similar in etiology except that the 
force in that instance drives the lower or basal fragment backward. Forc- 
ible reduction, under anaesthesia if need be, to reconstruct the normal 
arch of the palmar surface of the radius is demanded. Then a moulded 
gypsum splint to maintain the integrity of this arch or a metal splint 
similarly fitting the anatomical contour should be applied, permitting 
free motion of the ringers. Frequent removal of the retentive dressing, 
with light massage and mobilization, will complete the cure in about three 
or four weeks. 

After-results. — Basal fractures of the radius are very common, are 
often mistaken for sprains, are very frequently badly treated, because not 
reduced, and therefore cause patients and physicians much trouble. They 
are easily treated if promptly reduced and kept reduced. The dressing 
should be simple and frequently removed for inspection during the first 
ten days. Then it may be replaced by a gypsum encasement, split or not 
split, or an adhesive plaster cuff. 

Surgeons see every year cases that have not been reduced. Ref racture 
should then be performed if the injury is less than three months old. 
After that osteotomy is probably better. The incision should be made 
on the radial edge of the wrist. Sometimes there is great radial deviation 
from imperfect reduction of the fragments or crushing or impaction of 
bone ; sometimes the ulna may cause a prominence at the back of the wrist. 
The ulna may be shortened by removing a disk with the Gigli wire saw, 
if the radial displacement of the hand is great from shortness of the 
radius. If deformity arises from unreduced anterior displacement of the 
carpal fragment, osteotomy will be a means of relief, as it is in unreduced 
posterior displacement. 

It is a remarkable fact that many bad anatomical results are 
finally followed by fairly good functional results. Bad functional 



FBACTUBES OF THE EADIUS AND ULNA 459 

results are in most instances due to incomplete reduction of fragments. 
In a small number of cases, however, poor functional results are due 
to a perineuritis or a limitation of motion due to a coincident 
tenosynovitis followed by adhesions and circulatory disturbances. Many 
of these poor results will be obviated by passive motion and light massage 
and active movements of the fingers from the day of fracture. This is 
especially so in people of advanced years. In these cases the joints should 
not be allowed to stiffen. This may be prevented by soaking' in hot water 
after a daily removal of splints, light massage, and careful passive and 
active movements of the fingers from the minute full reduction has been 
made on the da}' of the accidental fracture. Bad results nearly always 
mean failure to reduce fragments, or incomplete reduction and prolonged 
immobilization. Both factors may be the cause of the bad results. 

When marked deformity persists after union, it is generally due to 
absence of reduction at the time of beginning treatment; and consists in 
posterior or anterior displacement with rotation and abduction of the 
lower fragment; the radius shortened, and the wrist broadened. In 
the rarer fracture with anterior displacement, failure to recognize the 
character of the break and reduce the lower fragment to its normal posi- 
tion is shown by a very prominent ulnar head at the back of the wrist. In 
unreduced ancient fractures the head of the ulna is very apt to be unduly 
prominent at the ulnar edge of the wrist. This deformity in the usual 
fracture with backward displacement may remain, even after wise treat- 
ment, in great comminution of the carpal fragment ; but it usually means 
that there was incomplete reduction. When the radius loses its normal 
length by absorption or crumbling of comminuted pieces this lateral prom- 
inence of the head of the ulnar may be permanent despite careful treat- 
ment. Fractures of the lower end of the radius have a reputation of being 
difficult to treat with favorable results. This opinion is due to the long- 
standing unwillingness of many members of the; profession to learn that 
complete reduction immediately after the receipt of injury is the keynote 
to success. Early complete reduction, even in impacted fractures, early 
superficial massage, and early mobilization, active and passive, will give a 
satisfactory functional result in the vast majority of fractures of the base 
of the radius. These fractures are especially satisfactory for treatment if 
the surgeon appreciates- the necessary factors in the management of the 
lesion. They prove the doctrines of Lucas-Championniere in regard to 
early mobilization and light massage to be of high significance in the 
treatment of fractures ; and especially so in bone injuries near joints. The 
vital factors in successful surgery of the usuaj fracture of the base of the 
radius are to give, as a general anaesthetic, nitrous oxide or ether, on the 
day of injury; break up impaction, loosen entanglement of fragments, 
restore the arch of the lower fifth of the palmar surface of the radius. 
Fixation is then to be provided. Partial flexion of the wrist is believed by 
Roberts to hold down the replaced fragment by tightening the extensor 



460 TREATISE OX FRACTURES 

tendons and thereby aiding in preventing recurrence of the backward dis- 
placement of the short carpal fragment. Other surgeons, as a rule, do not 
insist upon this position. A plastic splint moulded to the dorsum of the 
forearm and back of the hand is probably the best splint for use by the 
practitioner who only occasionally treats this injury. An expert can 
safely use almost any kind of a fixation appliance. Flexion of the wrist 
is bad position for the fracture with the lower piece displaced forward. 
That joint should be kept, after reduction, in the extended posture. 

Summary of Treatment of Fractures of Radius and Ulna 

reduction of the fragments to overcome displacement 

is the first step 

Fractures of Radius and Ulna Combined. — Upper Two-thirds of 
Shafts. — Flexed elbow, supination, anterior angular support with gyp- 
sum contour splint, wood or metal angular splint keeping elbow flexed. 
Sometimes additional posterior splint. Gypsum encasement after swell- 
ing, but must be split to give frequent inspection. Look out that round 
pronator does not pronate upper fragment of radius. 

Lowest Third of Shafts. — 

Immobilization of elbow not al- 

i 

bone 




Normal 

co of our ways necessary in lowest third 




Use an anterior and a posterior 
splint in midsupination. Operation 
if reduction is not maintained, and 
direct fixation. 

Fractures of Ulna (Isolated). — 

Olecranon, not quite fully ex- 

s P lint "" tended elbow with anterior straight 

Fig. 524. — Diagram showing injurious effect of 

straight anterior palmar splint in fracture of lower Splint Or PWPSUm-gaUZe COntOUr 
end of radius. r . . 

splint. Operation occasionally. 

Coronoid process, hyperflexion of elbow. Operation of excision 
sometimes needed. 

Shaft. — Upper two-thirds, flexed elbow, supination, anterior right- 
angle splint or gypsum-gauze contour splint to keep elbow flexed. 

Lowest one-third, flexed elbow, mid-supination, an anterior and a 
posterior splint; sometimes marked ulnar abduction of hand wise; or, 
if no displacement, anterior splint of gypsum, wood or metal only, from 
elbow to mid-metacarpal region. 

Fractures of the Radius (Isolated). — Head. — Flexed elbow; supina- 
tion, with anterior right angular splint to keep elbow flexed; or pronation 
with internal right angular splint. Operation for excision of head 
occasionally. 

Neck. — Flexed elbow, anterior right angle splint to keep elbow flexed, 
operation for excision of fragment occasionally. 

Shaft. — Upper one-third, flexed elbow, supination, right angle an- 



FRACTURES OF THE RADIUS AND ULNA 461 

terior splint or gypsum contour to keep elbow flexed. Middle and lower 
one-third flexed elbow, mid-pronation, anterior and posterior splints from 
elbow to metacarpal heads. Operation for direct fixation required with 
moderate frequency. 

Lower End or Base of Radius. — Be sure to break up impaction, 
reduce the lower fragment by pushing it forward, in the proper direction, 
with great force, if necessary, to restore normal arch of anterior surface 
of radius, In the usual backwardly displaced cases maintain wrist 
flexed with posterior contour splint of gypsum-gauze. If you do not flex 
wrist, employ posterior straight splint, or anterior and posterior straight 
splints with firm wedge-shaped pad under arched lower fifth of anterior 
surface of bone. 

Do not neglect to see at each daily dressing that the firm pad holding 
up the arch of radius at w r rist is in proper position and not flattened down 
by pressure of bandage and splint (see Fig. 524). Never use a Bond or 
a Carr splint. These were founded on a mistaken idea of the pathology 
of the fracture ; therefore they have a tendency to allow ^displacement 
backward. Remember that the deformity occurs in different degrees. It 
consists in displacement of the fragments in three manners in varying re- 
lations to each other: (1) backward, (2) rotation around a vertical axis 
so that the articular surface is deviated toward the radial border of the 
forearm, (3) rotation on a transverse axis so that the articular surface 
has its plane tilted toward the ceiling of the room. Correct these displace- 
ments and use fixation splint or splints. Treat fractures with forward dis- 
placement of the lower fragment in the same general manner, but reduce 
that fragment by pushing it backward instead of forward, and do not 
allow the radial arch to be increased more than is normal to the patient. 

Old unreduced fracture, ref racture or reconstruct bone by osteotomy. 



CHAPTER XVIII 

FRACTURES OF THE CARPAL BONES 

Anatomy. — The eight bones forming' the carpus (Fig. 525) are 
arranged in two rows, the proximal and the distal. Enumerated from the 
radial to the ulnar side the proximal row are : scaphoid, semilunar, cunei- 



Radius 



Flexor carpi radialis 



n 

Styloid process '4d? '/■§ 

Scaphoid 
Tuberosity of scaphoid 



Trapezium 
Ridge on trapezium 
Trapezoid 
Flexor carpi radialis <T/ 




Flexor carpi ulnans 

Styloid process 
Semilunar 
Cuneiform 
■Pisiform 
Os magnum 
Unciform 
Unciform process 
Flexor carpi ulnaris 



FlG. 525. — Anterior view of the bones of the carpus and the metacarpus. (Davis.) 



form, and pisiform; the distal row are : trapezium, trapezoid, os magnum, 
and unciform. 

The lower end of the radius and the lower surface of the triangular 
fibro-cartilage articulate with the upper surfaces of the scaphoid, semi- 
lunar, and cuneiform bones. The ulna is separated from the articulation 
by the triangular fibro-cartilage; the pisiform bone does not enter into the 
462 



FRACTURES OF THE CARPAL BONES 463 

articulation. The lower row of carpal bones articulates with the meta- 
carpals as follows : The trapezium with the first metacarpal, better called 
the proximal phalanx of the thumb; the trapezoid with the second meta- 
carpal; the os magnum with the third metacarpal; and the unciform 
with the fourth and fifth metacarpals. The carpal bones are irregularly 
shaped and take their names from objects which they resemble. 

The carpal ligaments join the bones of the forearm, the carpal and 
metacarpal bones together, and consist of the radiolateral ligament, the 
ulnar lateral ligament, the anterior radiocarpal ligament, the posterior 
radiocarpal ligament, and the transverse carpal or anterior annular liga- 
ment. In addition there are ligaments which unite the carpal to the 
metacarpal bones, and are known as the volar and dorsal intercarpal, 
the volar and dorsal carpometacarpal ligaments, and the volar and dorsal 
basal ligaments. 

Surface Markings. — The site of the radiocarpal joint is the space 
between the styloid process of the radius and the tubercle of the scaphoid, 
and its line is convex proximally. The line of the intercarpal joint corre- 
sponds to* the lowest transverse furrow in front of the wrist; this also 
marks the upper edge of the anterior annular ligament. On the flexor 
surface of the wrist the tubercle of the scaphoid may be felt below the 
styloid process of the radius, the trapezium below the tubercle of the 
scaphoid, the pisiform below the ulnar styloid, and the cuneiform to the 
inner side of the pisiform. 

Statistics. — Plagemann's statistics from Muller's surgical clinic at 
Rostock, based upon radiographic diagnosis of 1393 fractures, shows 
the carpal bones to be involved in 29 instances (2.08 per cent.), divided 
as follows : 

Per cent. 

Fractures of the scaphoid 13 0.93 

Fractures of the semilunar 5 0.359 

Fractures of the cuneiform 3 0.21 

Fractures of the os magnum 1 0.07 

Fractures of the scaphoid and semilunar 5 0.509 

Fractures of the scaphoid, semilunar and cuneiform .... 1 0.07 

Etiology. — Fractures of the carpal bones may be the result of direct 
violence, as a blow from a heavy instrument, or of indirect violence, as 
a fall upon the hand either in flexion or extension, and at times with the 
hand in rotation or abduction. They most frequently result from such 
forces as usually produce fracture of the base of the radius, viz., a fall 
upon the extended or hyperflexed pronated hand. They are occasionally 
seen in combination with fracture of the bones of the forearm, usually 
a fracture of the styloid of the radius or a comminuted fracture of the 
lower end of the radius. Carpal fracture may occur in conjunction with a 
dislocation of other carpal bones. The variation in frequency is well 
~shown in Plagemann's statistics. 



464 



TREATISE OX FRACTURES 



Symptoms. — Those common to fractures of any of the carpal bones 
are localized pain, tenderness on pressure, and local swelling - , and pain 
on movement of the wrist-joint, particularly on abduction or adduction. 
Many of these cases go unrecognized for weeks and are erroneously 
treated as sprains of the wrist-joint. At times there is a history of 
injury, followed by severe pain, swelling and tenderness, with pain on 
motion, which after a few days subsides to a certain degree but fails to 
entirely disappear. There is inability of full passive flexion or extension 
of the wrist- joint, which is accompanied by muscular spasm. There is 
generally no crepitus or ecchymosis present. Swelling persists; and the 



Fig. 526a. 




Fig. 526a. — Comminuted fracture of the carpal scaphoid. 
Fig. 5266. — Fracture of the carpal scaphoid. 



outline of the extensor tendons of the thumb is more or less obliterated 
by this persistent swelling, particularly in fractures of the scaphoid. 

In fractures of the scaphoid (Figs. 526(7-528(7) there is limitation of 
extension, local pain in the hollow between the extensors of the phalanges 
of the thumb when the hand is in the adducted position. The lesion is 
generally a fracture at the neck of the scaphoid, without much displace- 
ment of fragments. When displacement of fragments occurs, it is gener- 
ally the proximal fragment that is dislocated. Flexion of the wrist shows 
abnormal dorsal prominence formed by the scaphoid, anteroposterior 
thickening, and definite pain and tenderness over the scaphoid in the 
lateral region at the anatomic " snuff-box " and at times posteriorly. In 
old cases there will be found definite swelling over the radial half of the 
wrist- joint. In all cases anteroposterior and lateral radiograms should 



FBACTUEES OF THE CARPAL BONES 



465 



be made, so that a definite diagnosis may be made and the presence of 
comminution or displacement of fragments noted. It should be remem- 
bered that occasionally supernumerary carpal bones or additional centres 
of ossification may be mistaken for fractures of carpal bones, when X-ray 
examinations are made. 

Fractures of the semilunar are usually the result of great direct vio- 
lence, gunshot and open wounds, and are generally associated with other 
injuries. Fracture of the semilunar (Fig. 5286) shows local pain, tender- 
ness on pressure, and pain on motion, particularly on forced extension. 



Fig. 527a. 



Fig. 527b. 





Figs. 527a and 527b. — Sprain-fracture of the tubercle of carpal scaphoid. 

Swelling is marked over the region of the bone rather than being limited 
to the radial side, as in scaphoid fractures. 

Fractures of the cuneiform are extremely rare. They are the result 
of direct violence. The same may be said of the remaining carpal bones. 
The usual symptoms would be local pain, tenderness on pressure, and 
passive motion with local swelling. 

Diagnosis. — Injuries of the wrist-joint should be carefully studied 
clinically, and by radiography, always in two planes, when suspicious 
symptoms persist for more than a day or two and diagnosis is difficult. 
Actual fracture usually will show that active and passive movements at 
the wrist-joint are limited and painful; and attempts to continue passive 
motion beyond a certain degree probably will be followed by extreme pain 
and at times muscular spasm. Crepitus and ecchymosis are rarely ob- 
served, but swelling is persistent. When these symptoms last for a con- 
30 



466 



TEEATISE OX FRACTURES 



siderable length of time a diagnosis of carpal fracture may with propriety 
be made, and can often be confirmed by radiogram. 

Treatment. — The line of treatment to be adopted in the individual 
case depends upon the time which has elapsed since the receipt of the 
injury, and the occurrence or absence of displacement of fragments. 
When displacement of a fragment or fragments is present which cannot 
be overcome by manipulation, excision of one or several fragments should 
be performed. When there is no displacement of fragments and the 
patient is seen shortly after injury, attempts to secure union should be 
made during from four to six weeks. This is to be undertaken by placing 
the hand and forearm at rest upon a well-padded anterior splint of wood, 



Fig. 528a. 



Fig. 5286. 





Fig. 528a. — Fracture of the carpal scaphoid with backward luxation of the radial fragment, which 

was removed at operation. 
Fig. 5286. — Fracture of carpal semilunar, direct violence. • 

reaching from the bend of the elbow to the tip of the fingers, with the 
hand in semi-pronation. Instead of this dressing a well-fitting plaster-of- 
Paris case, which is better, may be used. If union has not resulted in four 
to six weeks, as shown by the radiogram, excision of one or both frag- 
ments should be performed if deformity or disability is sufficient to war- 
rant intervention. Whenever symptoms of discomfort or disability per- 
sist after excision, the parts should be immobilized for a period of two 
weeks, when active and passive motion should be begun. Supernumerary 
bones or unusual ossific centres should be differentiated from the supposed 
fracture before operation is performed for removal of a suspected frag- 
ment. Gouty or tuberculous disease might be the cause of the carpal pain 
and swelling. A single fragment may be held in place until union 
occurs by boring a small hole with a brad-awl and nailing it in position 
with a steel needle or a small wire nail. 



CHAPTER XIX 

FRACTURES OF THE METACARPAL BONES AND 

PHALANGES 

Anatomy. — The metacarpal bones (Fig. 525), five in number, sup- 
port the fingers and form the skeleton of the palm of the hand. The first 
bone, which is usually called the metacarpal of the thumb, resembles in 
development a phalanx. It may therefore be considered that a real meta- 
carpal bone of the thumb has been suppressed by Nature in the evolution 
of the human hand. They are long bones and may be divided into a base, 
shaft, and distal end or head. The bases articulate with the carpal bones 
and the heads articulate with the proximal phalanges. 

The metacarpophalangeal articulations are characterized by the fact 
that, while the articular surfaces are irregularly spherical, the range of 
motion is limited by the strong lateral ligaments, so attached to the heads 
of the metacarpal bones that they become tense on flexion of the phalanges. 
The capsules of the joints are also reinforced by the accessory volar and 
the transverse capsular ligaments. 

Surface Markings. — The metacarpal bones can be readily palpated 
throughout. The heads of the metacarpal bones form the first row of 
the knuckles. 

Etiology. — Fracture of the metacarpals by indirect violence are gen- 
erally due to force applied upon the distal end of the bone in its long axis, 
such as occurs in the striking of a blow or in a fall upon the flexed hand. 
The normal palmar arch of the bone is exaggerated, and fracture occurs. 
Fractures by direct violence are usually the result of a severe blow or 
crushing force on the back of the hand. Many direct injuries cause open 
and infected fractures of the metacarpus. Fractures are usually trans- 
verse or oblique, though occasionally spiral, fissured, or comminuted. A 
spiral fracture is most frequently observed of the fourth or fifth meta- 
carpals. Here a twisting force, such as a fall upon the back of the hand 
or the fingers, produces 1 the injury. Skillern and Speed have each de- 
scribed a diastasis of the second epiphysis sometimes occurring in the 
development of the base of the second metacarpal bone. Allan Thomp- 
son has shown that the metacarpal of the thumb is sometimes ossified by 
a third epiphysis at its distal end. These facts should not escape memory 
in skiagraphic study of the hand. 

Symptoms. — Fractures of the first metacarpal, or better called the 
first phalanx of the thumb, differ from those of the other four metacarpals 
to such an extent that they should be considered separately. Fractures 
of the shaft give the usual symptoms of fracture, but are rare. The usual 
fracture of the first metacarpal involves the base of the bone, and three 

407 



468 



TEEATISE OX FRACTURES 



Fig. 529c 



Fig. 5296. 




Fig. 529a. — Transverse fracture of first metacarpal at the junction of the base and the shaft. 
Fig. 5296. — -Oblique fracture of the shaft of the first metacarpal. 

C 




Fig. 530. — Ossification of bones of hand: (A) at birth; (B) latter half of first year; (C) at three years; 
(D) at eight years; (£) at twelve years, (a) Centres for shafts of metacarpals and phalanges; (b) magnum; 
(c) unciform; (d) cuneiform; (e) base of first metacarpal; if) heads of metacarpals; (g) bases of proximal 
phalanges; (h) bases of distal phalanges; (1) scaphoid; (J) trapezium; (k) trapezoid; (7) semilunar; (m) bases 

of middle phalanges; (n) pisiform. 



METACARPAL BONES AXD PHALANGES 



469 



varieties of fracture occur. The first variety (Figs. 529a and 529b) is a 
transverse or irregularly oblique fracture at the junction of the shaft and 
base not involving the articular surface, and is generally impacted. The 
second variety (Figs. S3 2a ~53 2c ) 1S tne oblique fracture, the line run- 
ning upward and backward through the base of the metacarpal; it is the 
so-called " stave of the thumb " or Bennett's fracture. The upper end 
of the lower fragment in this injury is displaced upward and backward, 
and resembles a subluxation of the metacarpal plus crepitus. This frac- 
ture is always observed in adults. The third variety (Figs. 533a and 533ft) 
of fracture is an epiphyseal separation of the basal epiphysis with a 
fracture through a small portion 
of the diaphysis. The symp- 
toms of all of these fractures 
are deformity, crepitus when 
impaction is absent, shortening 
of the thumb, and pain and 
tenderness on pressure. 

Fractures of the four other 
metacarpal bones (Figs. 534- 
538) are readily recognized by 
deformity, localized pain and 
tenderness on pressure, at times 
crepitus, shortening of the 
affected bone, and irregularity 
of the knuckle's outline in the 
hand affected. An infallible 
sign of fracture is pain at the 
seat of fracture on making di- 
rect firm pressure over the 
knuckle in the longitudinal 
axis of the bone (Fig. 539). 
Pain will often be elicited by 
the surgeon making traction on 
the finger and then pushing the bones of the finger toward the wrist. 
Open and infected fractures are usually easily demonstrable if due to 
crushing or gunshot injury. The fact that industrial injuries of the hand 
occur in many artisans while at work with necessarily unclean hands 
makes symptoms of sepsis a frequent complication. Comminution of 
bone is also common. 

Diagnosis. — In doubtful fractures, particularly those at the base of 
the second, third, and fourth metacarpals, radiograms should be made 
to establish the diagnosis. 

Treatment. — Impacted fractures of the base of the first metacarpal 
should be immobilized on a gutter splint of aluminum, or a moulded 
gypsum splint, for three or four weeks ; the impaction need not be inter- 




Fig. 531. — Bones of right hand, dorsal aspect. 



470 



TEEATISE OX FBACTUEES 








OIHlj 




METACARPAL BONES AND PHALANGES 

Fig. 533a. . Fig. 533b. 



471 






Figs. 533<* and 5336. — Separation of the epiphysis of the first metacarpal with a fracture of 

of the diaphysis. 



portion 



Fig. 534- 



Fig. 535- 




Fig. 534. — Separation of the epiphysis of the second metacarpal. Note callus formation about 

separation. 
Fig. 535. — Transverse fracture of shaft of fourth metacarpal. 

fered with unless deformity is great. In the other fractures of the first 
metacarpal, reduction should be made and maintained by the use of a 
gutter splint for three to four weeks (Figs. 540-542). Fractures of the 
other four metacarpals should be treated by reduction, consisting of 
traction and manipulation, and the corrected position maintained by a 
well-padded posterior splint of wood, extending from the upper third of 
the forearm to the tip of the fingers (Figs. 543-545). Immobilization 



472 



TEEATISE ON FRACTURES 




! ■ 


■ ■• ^' 


1 ■"•' 




- 




<. J - 





po+3 



§33 






:s™ 



-d-co 



o o <tf 



I I 9 



ro 



Ob 




METACARPAL BOXES AND PHALANGES 



473 



should be maintained for three to four weeks. It is frequently difficult 
to maintain proper apposition in oblique fractures of the shaft. When 
no deformity is present a palmar tin splint may be used (Figs. 546a- 
546c). The oblique fracture at base of the thumb may require permanent 
traction and countertraction with the digit in moderate abduction. Re- 
duction attained first by traction and direct inward pressure at the root 
of the thumb should be followed by a plastic splint of gypsum, modelling 
compound or gutta percha, or similar splint for about three weeks. 

In fractures of the shafts of the last four metacarpals, recurrent 
angular deformity sometimes may be overcome by the use of a tightly 
rolled muslin bandage placed in the palm of the hand with the fingers 




Fig. 539. — Method of determining crepitus and mobility of fragments in frac- 
ture of the metacarpals. 

flexed over it and held in place by suitable dressing and a bandage. In 
some instances a hard ball of rubber, ivory, or celluloid placed in the palm 
will probably answer the purpose better. When overriding of fragments 
persists, permanent traction and countertraction may be used. Satisfac- 
tory traction is readily made by fastening lateral strips of adhesive plaster 
to the finger and tying their distal ends to- a thin rubber loop attached to a 
tack driven into the end of a palmar splint of wood fixed to the forearm 
and extending beyond the finger-tips. To secure countertraction the 
board should be cut narrow just above the thenar eminence, and be fixed 
to the wrist by a wristlet of adhesive plaster. Another good method is to 
reduce the fragments and nail them together with a brad-awl and a 
straight surgical needle or a carpet tack. This is especially available in 
oblique fracture near the head caused by boxing. 

After-results. — The great majority of fractures of the metacarpals 



474 



TREATISE ON FRACTURES 

Fig. 540. 




Figs. 540, 541, and 542. 



-Method of application of padded gutter aluminum splint for 
fractures of the first metacarpal. 



are followed by good functional results, even in the presence of moderate 
deformity. Epiphyseal separation of the metacarpals may be followed 
in later life by failure of development of the metacarpal and subsequent 
shortening with deformity (see Fig. 548). 



METACAEPAL BONES AND PHALANGES 



475 



The severe injuries with crushing of several metacarpals arising in 
industrial accidents demand expert surgical treatment to avert unneeded 
loss of manual function. These comminuted, contaminated, and usually 
infected fractures should not be left to the discretionary treatment of 
occasional surgeons or hospital subordinates. Immediate antisepsis, 
careful haemastasis, omission of amputation or excision of bone except 



Fig. 543- 




; 



Fig. 544- 



■J 




Fig. 545. 



Figs. 543, 544, and 545. — Method of application of padded posterior wood splint for fractures 
of the second to the fifth metacarpals. 

under competent surgical supervision, and sufficient delay for observation, 
will save many workmen the loss of portions of the hand urgently needed 
in occupation. Plastic reconstruction, immediate or delayed, will preserve 
many phalanges and metacarpal bones. 

Fractures of the Phalanges 

Anatomy. — There are three bones or phalanges in each of the fingers. 
The first, or proximal phalanx of the thumb, is often termed the first 
metacarpal bone ; but it is developed like a phalanx, having a separate ossific 



476 



TKEATISE ON FRACTURES 



centre for its base instead of for its head. They may be divided into the 
proximal or first row, the middle or second row, and the distal or third 
row. Like all long bones, they have two extremities and a shaft. The 
interphalangeal articulations are constructed by the bases furnishing shal- 

Fig. 546a. 




Fig. 5466. 




Fig. 546c. 






Figs. 546a-546c. — Method of application of padded palmar splint for 

fracture of the second to fifth metacarpals, when a tendency to recurrence 

of deformity is not present. 

low sockets, and the trochlear surfaces of the heads completing the joints. 
They are held together by lateral ligaments and anterior ligaments. 
Posterior ligaments are not present but are substituted by the tendons 
of the extensor muscles. 

The lines of the interphalangeal joints may be determined by the 
position of the transverse furrows on the palmar surface of the ringers. 



METACAEPAL BOXES AXD PHALANGES 



477 



The first furrow is midway between the metacarpophalangeal articulation 
and the joint between the first and second phalanx; the two remaining 
furrows represent the position of the interphalangeal joints. The distal 
ends or heads of the first phalanges form the second, and the distal ends 
or heads of the second phalanges form the third row of knuckles. 

Etiology. — Fractures of the phalanges (Figs. 549-553) are usually 
caused by direct violence, such as blows and machinery accidents, but 





Fig. 547. — Palmar splint for elastic traction in fracture of metacarpal bones. 

A rubber tube under splint is attached to finger by adhesive plaster strip going 

over end of splint. A small pad is placed over seat of fracture before 

applying roller bandage. (Cotton.) 






Fig. 548. — Results of amputation above metacarpophalangeal articulation in middle, index, and ring 

fingers. (Erichsen.) 

occasionally are the result of indirect violence, such as a fall upon the 
tip of the extended finger or a blow as in catching a baseball. Fractures 
by direct violence may involve any portion of the bone, while those 
produced by indirect violence are more commonly noted as involving 
the base of the phalanges. Many of the fractures of the phalanges are 
compound, which is due usually to the nature of the injury and the sub- 
cutaneous character of the bones. Fracture of the phalanges may be 
fissured, multiple, comminuted, oblique, transverse, and articular. Those 
due to industrial crushes are apt to be open and infected. Epiphyseal 



478 



TREATISE OX FRACTURES 

Fig. 549. FlG - 550. 




FlG. 549. — Transverse fracture of proximal phalanx of thumb. 
FlG. 550. — Comminuted fracture of proximal phalanx of fifth finger. 



Fig. 551. 




Fig 552. 




<* 'A 








\- 


\ 






#^^^1 


tt y > 


-• i 


f, *^ 


J» 


; m- 


■V - 




T 




^ ]«k B 










. 



Fig. 551. — Articular fracture of base of middle phalanx of third finger. "Base ball" finger. 
Fig. 552. — Articular fracture of head of middle phalanx of thumb. "Base ball" thumb. 

separations in the phalanges are possible in persons not over 20 years 
of age, as is the case in metacarpal traumatisms. 

Symptoms. — The symptoms of fracture of the phalanges are local- 
ized pain, swelling, tenderness on pressure, deformity, abnormal 



METACAEPAL BONES AND PHALANGES 



479 





Fig. 553.- 



-Separation of epiphysis of proximal 
phalanx of ring finger. 



Fig. 554. 



mobility, crepitus, and widening 
at the seat of fracture with slight 
displacement. As many of these 
fractures are open, there is in 
addition direct evidence of the 
presence of the fracture. 

Diagnosis. — D iagnosis of 
fracture of the phalanges can, as 
a rule, be readily made, even with- 
out the radiogram. Difficulty will 
at times be experienced in diagnos- 
ing articular fractures; here the 
use of the radiogram will mate- 
rially help in diagnosis. However, 
in its absence a diagnosis may be 
made by widening of the bone, 
deformity, preternatural mobility, 
and the tendency toward displace- 
ment which is present. 

Treatment. — In the treatment 
of phalangeal fractures reduction 
is generally accomplished by trac- 
tion and maintained by the use of 
a padded wood or tin or alumi- 
num splint (Figs. 554~5570 ap- 
plied to the flexor surface of the 
palm of the hand and fingers and 
held in place by adhesive plaster 
and bandage. Gypsum encase- 
ments or trough splints of gutta- 
percha or other plastic material 
will often be better than wooden 
splints. In some cases deformity 
may be prevented by splinting the 
injured and the next finger to- 
gether. In some fractures in • 
which deformity is recurrent, it 
may be prevented by the use of a 
traction apparatus like that sug- 
gested for metacarpal fractures. 
Union is to be expected in uncom- 
plicated fracture in about two 
weeks. Lateral and rotary devia- 
tion is to be corrected with especial ■ 

rQrp A nmnlrfiA fi-no-At- ic tint r-ml-ir Figs. 554, 555, AND SS6.— Method of application of padded 

Care. /\ CrOOKeCl nnger IS not Ollly a i um i num splint for fractures of phalanges of index finger. 




FiG. 555- 




Fig. 556. 




480 



TREATISE ON FRACTURES 



unsightly but may interfere with manual dexterity, so important to an 
artisan. Bowing of the middle of the shaft of a phalanx toward the 
palm must be avoided because it prevents an efficient grasp. If ankylosis 
is apprehended, the finger should be slightly flexed during treatment. 

A partially bent finger is less 

Fig. 557a. .1111 • 

noticeable and less inconvenient 
than a rigidly extended one. If 
the proximal phalanx is broken, 
the splint should include palm 
and wrist. Some fractures may 
be held in position after reduc- 
tion by circular strips of ad- 
hesive plaster superimposed so 
as to make an encasement. 

In open fractures the wound 
should be thoroughly sterilized 
with iodine or other antiseptic 
and closed, and then treated as 
a simple fracture. Necrosis of 
bone may follow in some cases 
and the final result may be heal- 
ing with loss of bony structure. 
Open and comminuted frac- 
tures should not be subjected to 
hasty amputation, because fin- 
gers may often be saved by 
plastic procedures. Denuded 
bones may be covered with 
tegumentary flaps from other 
fingers or parts of the hand. 
In some cases the stripped bones 
may be inserted into a space 
or pocket, made by an incision 
or incisions in the skin and 
superficial fascia of the patient's 
abdomen or thigh, and thus provided with cutaneous covering. In other 
instances free flaps may be transplanted to the hand and the denuded 
phalangeals may be subsequently modelled into useful fingers. These 
procedures are particularly valuable when the thumb is injured, because 
its opposing pressure against another part of the hand or even a stump 
of a finger gives the patient a grasp. 

After-results. — Union occurs in closed fracture in three to four weeks. 
In articular fractures union may occur with ankylosis of the opposing 
joint surfaces. Early light massage and early passive movements may 
avert this contingency. In infected fractures healing may follow only 
after necrosis and loss of bony structure. 




Figs. 557a-557c. — -Method of application of padded alum 
inum splint for fractures of phalanges of fingers. 



CHAPTER XX 

FRACTURES OF THE PELVIS 

Anatomy. — The pelvis (Figs. 560 and 561) is formed by the two 
innominate bones, the sacrum, and the coccyx. The innominate bone 
in the adult consists of a single bone, formed by fusion of its three con- 
stituents — the ilium, ischium, and pubes. In childhood it consists of these 
three bones separated by a Y-shaped cartilage in the floor of the acetabu- 
lum. This ossifies and unites the segments about the fourteenth or fif- 
teenth year of life. The pelvis is a strong basin-shaped cavity divided 
for description into the upper or false pelvis, between the iliac bones and 




Fig. 558. — Lines of fractures of the pelvis. (Piersol.) 



upper part of the sacrum, and the lower or true pelvis situate between 
coccyx, lower part of the sacrum, the pubes, ischium, and lower part of 
the ilium. The true pelvis communicates with the upper pelvis at the 
iliopectineal line through the inlet called the superior strait. Its opening 
below is called the outlet or inferior strait. When the trunk is erect the 
pelvis is placed obliquely so that the axis of the superior strait is directed 
upward, forward, and the axis of the inferior opening downward. The 
true pelvis holds and protects the urinary bladder, the uterus, vagina, 
rectum. The lower sections of the intestinal canal, except the rectum, 
occupy the false pelvis, as does the uterus after the early weeks of preg- 
nancy. The so-called pelvic girdle consists of the two innominate bones 
with the sacrum, a bone of the trunk, filling the gap posteriorly. The 
innominate bone is irregular in form, shaped like the blade of a screw- 
propeller. It is narrow near its centre, where the acetabulum or socket for 
the head of the femur exists, and expanded above and below this region. 
The ilium is the largest of the three segments, forms about the upper third 
31 4S1 



482 



TREATISE OX FRACTURES 



Upper centre 
appears at birth. 
Unites about 
20 years of age. 



Ossification of 
diaphysis 
begins abcut ;th 
week of intrauter- 
ine life. 




of the acetabulum, and consists of an expanded portion, called the ala. 

and the body. The ischium is composed of a body and two rami, the 
superior and the inferior, which form the pos- 
terior and inferior boundary of the obturator 
foramen. Its body forms approximately the in- 
ferior two-fifths of the acetabulum, and terminates 
at its postero-inferior part in the tuberosity of 
the ischium. The pubic bone has a horizontal 
and a descending ramus and forms the anterior 
inferior portion of the innominate bone. It con- 
sists of a body articulating in the median line of 
the human trunk with the body of the opposite 
pubic bone and the two branches or rami men- 
tioned above. The body forms the anterior part 
of the acetabulum, and the superior and inferior 
rami form the antero-inferior boundary of the 
obturator foramen. Where the os pubis joins 
that of the opposite side anteriorly, there is fibro- 
cartilage forming part of the synchondrosis ; this 
generally becomes ossified at puberty. The in- 
ferior ramus is separated from the inferior ramus 
of the ischium by cartilage which becomes ossified 

about puberty. Together these two rami form the lower border of the 

obturator foramen. 

The ligaments of the pelvis are the following: Pubic articulation, 

Crest of ilium 
External lip 



^-•SS/i'^N- 



Lower ossific 
centre appears 
at 2nd year. 
Unites about 
1 8 th year. 



Fig. 559- — Development of 
tibia bv three rer.tres. 



Ilium 



Super! :r gluteal line 



Posterior superior spine 

Posterior border 

Posterior inferior spine 

Great sacrosciatic notch 



Body of ischi 



ip:re c: :sc 

Obturator foramen 
Tuberosity 

Ischium 
Fig. 560. 




Middle gluteal line 
4- Anterior superior spine 



Anterior border 
Inferior gluteal line 

Anterior inferior spine 



Articular surface 
Acetabulum 

Xcr.articuLar surface 



Cotyloid notch 

Inferior ramus 



Ischial ramus 



-Right innominate bone, outer aspect. (Piersol.) 



superior pubic ligament, inferior pubic ligament, anterior pubic, posterior 
pubic, and subpubic, and the interposed fibro-cartilage : sacro-iliac articu- 
lation, the anterior sacro-iliac ligaments, the short posterior sacro-iliac 



FKACTURES OF THE PELVIS 



ligaments, the long posterior sacro-iliac ligaments; the connection of 
sacrum with ischium is by the great or posterior sacrosciatic ligament, 
the small or anterior sacrosciatic ligament, and the interosseous sarco- 
sciatic ligament. The ilium is joined to the fifth lumbar vertebra by the 
iliolumbar ligaments. 

Surface Markings. — The ala of the iliac bone may be palpated laterally 
as well as the spine of the pubes anteriorly. Posteriorly may be felt 
the posterior superior iliac spines, which are on a level with the middle 
of the sacro-iliac joint, the two tubercles of the last sacral vertebra, the 
base and tip of coccyx, and the tuberosities of the ischia. 

The bladder occupies the anterior part of the pelvis, situated between 
the pubic bones and the rectum in the male and between the pubic bones 
and the uterus and vagina in the female. In extraperitoneal rupture of 



Crest of ilium 

Articular surface 
for sacrum 

Ilium 

Promontory of 

sacrum 

Anterior superior 

spine 

Inferior superior 

spine 

Iliopectineal line 

Body of pubis 

Spine of ilium 

Acetabulum 

Spine of pubis 

Symphysis 

Tuberosity of 
ischium 




Spinous process 
Articular process 
Body of sacrum 

Transverse process 
Iliac fossa 

Sacrum 

Sacral foramina 

Coccyx 
Oburator foramen 



Fig. 561. — Male pelvis, anterior view. 



the bladder extravasation of urine is limited by the reflection of peri- 
toneum known as the posterior false and lateral false ligaments of 
the bladder. 

Statistics. — Plagemann's statistics from Miiller's clinic at Rostock, 
based upon the rontgenographic diagnosis of 1393 fractures, shows 
17 cases (1.22 per cent.) of fracture of the pelvis, divided as follows: 
Pelvic girdle fractures, 6 cases ; acetabulum fractures, 5 cases ; isolated 
fractures of the pubes, 3 cases; and isolated fractures of the ilium, 3 
cases. J. Jensen collected the records of four Copenhagen hospitals for 
five years, and found 80 cases of fracture of the pubes, shown by ront- 
genoscopy, operation, or necropsy. Of this number the 25 fatal cases 
showed that the trauma had more serious consequences at other points, 
excepting in three cases, in which the patients died as a result of com- 
plications of the fracture, and one, a child, who died as a direct result 
of the accident. In 6 cases the pubes alone was fractured, and in 2 cases 
there were isolated fractures of the sacrum and ilium. In 55 clinical 



484 



TREATISE OX FRACTURES 



cases there was isolated fracture of the pubes in 22 instances, and pubic 
fracture associated with fracture of the ischium in 7 instances; isolated 
fracture of the acetabulum in 5 instances; isolated fractures of the ilium 
in 9 instances ; and in 2 cases either the sacrum or the ischium alone was 
fractured. In 2 there was a double vertical fracture, in 6 fracture and 
dislocation, and in 2 dislocation alone. In 21 cases there were compli- 
cations of the urinary system, including 5 with a fatal result. There was 
urinary retention in 16 cases, but in 5 cases of this group the urine was 
normal; dysuria in 2 cases; the urethra was ruptured in 3 cases, and the 
bladder in 3 cases — the latter all proved fatal. Recent studies, following 



Crest of ilium 



Posterior _ superior 
iliac spine 



Posterior surface 
capsule of hip- joint 



Great trochanter- 



Posterior surface of. 
obturator mem- 
brane 

Small trochanter 1 



Spinous process 5th lumbar vertebra 



Dorsum of ilium 




Spine of ischium 



Coccyx 



Tuberosity of 

ischium 



Posterior surface of 
pubic symphysis 



Fig. 562. — Posterior view of bony pelvis and upper end of femur. 

the more or less routine use of radiography, have taught surgeons that 
fractures of the pelvis are much more common than was supposed. This 
refers especially to breaks of the pubes and ischium. 

Fractures of the pelvis, as a rule, require a great degree of violence 
for their production, although there are cases in which the fracturing 
force is relatively slight. Injuries of the component parts of the innomi- 
nate bone may result from moderate forces; but fractures of the pelvic 
ring girdle itself seldom arise unless the force has been great. They 
may be the result of direct or indirect violence, and rarely of muscular 
action. Falling embankments or elevator cars, the passage of vehicles 
across the pelvis, crushing force such as being caught between the bumpers 
of cars, blows, falls from a height, and very rarely sudden muscular strain, 
are the kinds of injuries by which fracture of the pelvis is generally caused. 
Transmitted force, such as falls upon the feet or trochanter, may produce 
these lesions. The fracture lines are usually multiple, rarely compound, 



FRACTURES OF THE PELVIS 



485 



and are dangerous to life on account of the damage to the pelvic contents 
which may result in conjunction with the fracture. 

The character of fracture depends upon the direction of the force, 
and is usually limited to certain definite areas, except when the vulnerating 
force is an extreme form of crushing. Fractures occur where the thin 
portions of the bone unite with the thicker portions, or where the pubic, 
iliac, and ischiatic elements of the bone before adult life are united by 
cartilage. The pelvis, as shown by Katzenelson, consists of two semi- 




FiG. 563. — Fracture of pelvis. Fracture involves the body and descending ramus of the right 
pubis, and the ascending and descending rami of the left pubis. 



circles, each formed of an anterior and posterior arm, with the acetabulum 
as the summit. In the anterior arm the line of fracture occurs at the 
tuberosity of the pubes, the iliopectineal line, the ascending ramus of the 
ischium, and at the junction of the ascending ramus of the ischium with 
the descending ramus of the pubes. In the posterior arm the fracture 
line passes vertically from the pelvic bone down through the greater sciatic 
notch of the ilium, through the lateral masses of the sacrum, irregularly 
diagonal through a portion of the ilium and sacrum, and through the 
sacro-iliac synchondrosis. 

Varieties. — Fractures of the pelvis may be classified: 
Fractures of the rami of the pubes (Figs. 563 and 564) occur 
from direct violence directed from in front either posteriorly or laterally, 



486 



TEEATISE ON FRACTURES 



and are the most common form of fracture. The line of fracture passes, 
as a rule, through the superior ramus of the pubes anterior to the ilio- 
pectineal eminence and through the inferior ramus of the pubes. At 
times the latter line is very oblique and passes through the inferior ramus 
of the ischium. There may or may not be an accompanying separation 
of the sacro-iliac synchondrosis. Displacement of the fragments may 
be marked. 

Fracture of the Rami with Fracture of the Posterior Arm 
of the Pelvic Arch (Figs. 565 and 566). — In this fracture the anterior 
fracture line passes through the superior ramus of the pubes or the ramus 




Fig. 564. — Fracture of the pubis. Lines of fracture go through the junction of the superior and inferior 

rami of the right pubis and through the inferior ramus of the left pubis and inferior ramus of the left 

ischium. (Courtesy of Dr. P. G. Skillern, Jr.) 



of the ischium, and the posterior part of the fracture line passes vertically 
through the ilium behind the acetabulum, or through the sacrum, or par- 
tially through the ilium, the sacrum, and the sacro-iliac synchondrosis. 
It has been called the double vertical fracture of Malgaigne. The injury 
occurs from anteroposterior or lateral crushing. Marked displacement 
of the middle fragment often results. This fragment, consisting of the 
acetabulum with the attached head of the femur, is generally displaced 
upward with the leg, and it may rotate around a vertical or horizontal 
axis, so that the shape of the pelvis is altered and the extremity of the 
involved side apparently shortened. 

Separation of the symphysis of the pubes (Fig. 567) occurs be- 
tween one of the pubic bones and its attached cartilage, rather than 
between the two cartilages which belong to the joint. This separation may 



FRACTURES OF THE PELVIS 



48 ? 



be the result of parturition, forced abduction of the thighs, or by direct 
external violence. The gap between the two bones may be several inches 
in width ; occasionally the fracture is an open one. 

Separation of the sacro-iliac synchondrosis (Fig. 568) is ex- 
tremely rare. Cases have been reported by Malgaigne and by Stimson. 
It is truly a dislocation. Much has recently been written on partial 




Fig. 565. — Fracture of the pelvis. The anterior lines of fracture involve the body and 
descending rami of the pubis, and the posterior line passes vertically through the ilium 
behind the acetabulum close to the sacro-iliac synchondrosis; the so-called "double 
vertical fracture" of Malgaigne. 



luxation here being frequent and causing painful backs. Doctor Gold- 
thwaite, of Boston, has given this injury great attention. 

Separation of the symphysis of the pubes and the sacro-iliac 
synchondrosis has been observed by Malgaigne, Earle, Creite and Sal- 
leron. In the reported cases the injury occurred through a fall from a 
height upon one foot, cr from the pressure of a heavy weight upon the 



4:88 



TREATISE ON FRACTURES 




Fig. 566. — Pelvis with fourth and "fifth lumbar vertebrae. Fracture of the symphysis, body 

and ramus of the pubes, of the ramus of the ischium, with the sacro-iliac separation and 

fracture of the fourth body of the sacrum. (Mutter Museum, 1382.20.) 




Fig. 



567. — Fracture of the pelvis. The line of fracture involves the body and the symphysis 
of the pubes with separation of the synchondrosis of the latter. 



FRACTURES OF THE PELVIS 



489 




Fig. 568. — Pelvis: fracture of the sacrum and left innominate. The first and second sacral 
vertebrae are crushed and the body of the pubes and ramus of the ischium are fractured. 
(Mutter Museum, No. 1367.) 




Fig. 569. — Fracture of the floor of the acetabulum with central dislocation of the head of the 
right femur into the pelvic cavity and partial separation of the pubic synchondrosis. The 
greater trochanter is in close relation to the upper rim of the acetabulum. (Case of Dr. W, T. 

Ellis.) 



490 



TREATISE ON FRACTURES 



pelvis. Displacement consisted in elevation of the affected half of 
the pelvis. 

Separation of the symphysis of the pubes and of both sacro- 
iliac synchondrosis is extremely rare. The few reported cases were 



Fig. 570. 



Fig. 571a. 



Fig. 5716. 




Figs. 570, 571a and 57 ib. — Photographs of case of fracture of the floor of the acetabulum with cen- 
tral dislocation of the head of the femur. (See Fig. 569.) Lateral view shows absence of normal promi- 
nence of greater trochanter; anterior view shows tilting of pelvis with shortening of the distance 
between the anterior superior spine of the ilium and the greater trochanter, and the posterior view 
shows spinal curvature and flattening of gluteal crease on the right side. 

accompanied by multiple fractures of the pelvis and were the result of 
extreme violence. 

Fractures of the acetabulum (Figs. 568-575) may occur as a 
radiating fracture in the direction of the conjugal Y-eartilage seen in 
adolescence, in which the fracture line runs into the sciatic notch, the 
obturator foramen, and over the brim of the pelvis. Other forms of frac- 



FRACTURES OF THE PELVIS 491 

ture are those associated with fracture through the rami of the pubes and 
are irregular in character, those involving the rim of the acetabulum in 
association with partial dislocation of the head of femur, and those in 
which there is fracture of the acetabulum with incomplete or complete 
penetration of the head of the femur through it into the pelvic cavity, 
the so-called central luxation of the femur. These fractures are usually 
the result of great violence applied directly upon the side of the pelvis 



/ 





Fig. 572. — Fracture of the pelvis. An incomplete form of the so-called "central 

dislocation of the head of the femur." The line of fracture involves the floor 

of the acetabulum and extends posteriorly into the great sacrosciatic notch. 

and great trochanter or against the external and upper surface of the 
thigh with the thigh in the position of marked abduction. 

Isolated fractures of the sacrum are rare and the lesion most 
frequently reported is a more or less transverse fracture below the 
sacro-iliac synchondrosis with displacement of the lower fragment into 
the pelvis. This fracture results from great direct violence applied from 
behind or from a fall upon the sacrum. 

Isolated fractures of the ilium (Figs. 576-579) may consist of 
a fracture of the expanded portion in which the line is irregular and 



492 



TREATISE OX FRACTURES 




Fig. 573- — Fracture of the pelvis. Incomplete central luxation of the head of the 
femur due to fracture of the acetabulum. Note the line of fracture extending 
through the floor of the acetabulum, with central displacement of the floor of the 
acetabulum and of the head of the femur. Lessening of the distance between 
the superior rim of the acetabulum and the inner surface of the great trochanter 
of the femur. 



Fig. 574. 



Fig. 575- 




Fig. 574- — Portion of left innominate bone. Multiple fracture; recent. All the fractures communicate 
with the obturator foramen. The ramus of the ischium is fractured in its transverse diameter at the 
lowest portion of the obturator foramen. The ramus of the pubes is fractured in a line running from 
the angle downward and to the left. The acetabulum is fractured vertically, line runs from the ilio- 

pectineal groove to the cotyloid notch. (Mutter Museum, No. 1382.) 
Fig. 575- — Right innominate. Fracture of the acetabulum and pubes. (Mutter Museum, No. 1382.48.) 



FBACTUBES OF THE PELVIS 



493 



more or less transverse, or a fracture of the epiphysis of the crest. Com- 
minuted fractures are also seen. These fractures are generally the result 
of direct violence applied from the lateral aspect; although a case has 
been reported by Hamilton in which there was a tearing off of a part 
of the crest and the anterior superior spine. Cotton reports one in which 
the anterior superior spine alone was torn off, the result of muscular 
action. Similar cases have been reported by various authors, all of 
which occurred in young subjects and were in all probability due to the 
action of the sartorius muscle, generally occurring during running. 



\ 



S 



lm 



Fig. 576. — Irregular fracture of ala of ilium. The line of fracture runs downward 
from the crest of the ilium to the superior rim of the acetabulum. Direct violence. 

Isolated fracture of the ischium is rare. Few cases have been 
reported. The lesion consists in a fracture through the ischium itself in 
some cases, while in others only the tuberosity is fractured. They are 
usually the result of a fall upon the buttocks. 

Isolated fractures of the coccyx are the result of a fall upon 
the buttocks, or a kick, or during parturition. Bony union of the coccyx 
with the sacrum occurs in late adult life in many cases, so that fracture 
at that point is possible. Many so-called cases are undoubtedly coccy- 
godynia and partial dislocation. 



494 



TEEATISE ON FRACTURES 



James F. Mitchell made an elaborate study of pelvic fractures com- 
plicated with rupture of the bladder. S. P. Mengel has recently collected 
and analyzed a series of fractures of this region. These papers deserve 
careful reading. 

Symptoms. — Fractures of the pelvis as a rule are not accompanied 
by very great displacement of fragments unless the crushing force 
has been great or the comminution marked. It is possible that in some 
the original displacement has decreased by a springing back into place 




i 





Fig. 577. — Fracture of the anterior superior spine of the ilium. Direct violence. 



of the fragments after the traumatic pressure has been released. Shock 
is a prominent symptom of fractures involving the ring of the pelvis, 
not so much on account of the fracture itself as on account of the great 
force usually requisite in the production of the injury, and because of 
the associated intrapelvic injuries. Displacement of fragments varies 
with the variety of fracture. In fractures of the rami, and in separation 
of small portions of bone, as of the crest of the ilium, and tuberosity of 
the ischium, deformity is not evident on inspection. Fractures in the 



FRACTURES OF THE PELVIS 



495 



front of the pelvis with displacement inward are evident on mere inspec- 
tion. In the double vertical fracture of Malgaigne, there is usually 
marked displacement upward of the middle portion, including the hip; 
in addition the anterior superior spine and crest of the ilium are carried 
upward and outward. This is readily recognized on inspection. In trans- 
verse fracture of the ilium, inspection shows deformity upward with 
apparent lengthening of the leg. Transverse fracture of the sacrum may 




Fig. 578. — Normal epiphyseal line of the crest of the ilium. This epiphysis 

unites with the diaphysis about the twenty-first year. The line of the epiphyseal 

cartilage has often been mistaken for a fracture. 



be recognized by the presence of a ridge at the seat of fracture. Fracture 
of the upper and posterior rim of the acetabulum simulates posterior dislo- 
cation of the hip, while fracture of the acetabulum with penetration of the 
head through the acetabulum into the pelvic cavity shows loss of the 
normal prominence of the trochanter, shortening of the leg, relaxation 
of the fascia lata, and approximation of the great trochanter to the 
acetabular rim and to the symphysis pubis (Fig. 580). Fracture of the 
anterior superior spine also may at times be recognized on inspection. 



496 TREATISE OX FRACTURES 

Separation at the symphysis pubis shows broadening of the trochanters, 
with evidence of bulging at the symphysis. 

Of chief importance as symptoms of fracture are the facts derived 
from careful palpation. Palpation should be carefully made in all cases. 
By this means abnormal mobility, crepitus, localized pain and tenderness 
may be -elicited. Individual bones may be palpated by studying the unin- 
jured side of the pelvis with one hand and with the other carefully going 
over the external aspects of the bone in the region of the suspected frac- 
ture. Lateral compression of the pelvis in the region of the crests of 



fM 


jp&m^ 








lib; 


V- 



Fig. 579. — Left innominate; old fracture; exostosis. It 
has been doubtless an old fracture of the crest of the 
ilium. On both sides of the seat of fracture, especially 
the outer, there are exostoses. There is also an exostosis 
of the pubic bone. (Mutter Museum, No. 1382.50.) 

the ilia or of the trochanters will demonstrate many fractures (Fig. 581). 
Pressure directed upward in the line of the thigh with the hip and knee 
flexed will often produce pain and at times crepitus and abnormal mobility 
(Fig. 582). Palpation through the rectum or vagina may demonstrate 
irregularities of outline and abnormal position of fragments, and elicit 
pain and crepitus. Examination by these routes enables the surgeon to 
palpate the posterior wall of the symphysis and the rami of the pubes, 
the acetabulum, the ascending ramus of the ischium, the sciatic notch, 
and posteriorly the coccyx and the promontory and upper portion of 
the sacrum. 



FRACTURES OF THE PELVIS 



49' 



Of the subjective symptoms of fracture, there may be mentioned 
pain, accentuated on pressure or movement, tenderness, inability to move 
the leg at times or to bear weight on the injured side, ecchymosis, and 
disturbed function. Inability to flex the leg may be due to nerve injury, 
to infiltration of the psoas muscle with blood, or to splintering and punc- 



c 




J 

Fig. 580. — Method of measuring the distance from the median line of the abdomen to both 

trochanters to determine inward displacement of the trochanter in fracture of the acetabulum 

with dislocation of the head of the femur into the pelvic cavity. 




Fig. 581. — Method of lateral compression to determine crepitus and mobility in suspected frac- 

' ture of the pelvis. 




Fig. 582. — Method of determining crepitus and mobility in suspected fracture of the rim of the 
acetabulum or in Malgaigne's double fracture of the pelvis. 



ture of the muscle by sharp fragments of bone. This movement may 
also be impaired because the head of the femur will not stay in its normal 
position and has lost its point of purchase, as in fractures of the acetabu- 
lum. Walking is difficult and in most cases impossible on account of 
the pain and an inability of the leg to properly support the weight of the 
body transmitted through the pelvis. 
32 



498 TEEATISE OX FKACTUBES 

Areas of ecchymosis above Poupart's ligament are diagnostic of 
fracture of the pelvis and distinguish them from fractures of the neck 
of the femur, in which the ecchymosis is below the ligament. Later 
ecchymosis appears in the region of the scrotum, perineum, hip, and 
sacrum, depending upon the site of fracture. 

In separation of the symphysis pubis there may be a palpable sulcus 
or furrow between the two innominate bones. In addition there is local- 
ized pain, tenderness on pressure, local ecchymosis, and abnormal move- 
ment on alternate rocking of the two sides of the pelvis, and especially 
on forced abduction of the thigh. Rigidity of the adductors of the femur 
found after injury to the pelvis is suggestive of fracture of the pelvis. 

Of particular interest are the fractures of the acetabulum associated 
with penetration of the fragments by the head of the femur into the pelvic 
cavity. The characteristic symptoms are apparent shortening of the leg, 
loss of prominence of the trochanter major, loss of tension of the fascia 
lata, outward rotation of the thigh with loss of motion, and the presence 
on rectal or vaginal examination of the fractured acetabular floor and 
prominence of the head of the femur in the pelvic cavity. 

Fractures of the rim of the acetabulum simulate dislocation of the 
head of the femur, the usual lesion being a breaking off of the posterior 
and upper edge of the joint socket. The symptoms are those of a back- 
ward dislocation of the head of the femur with crepitus, and a tendency 
toward recurrence of the dislocation after reduction. In this fracture, 
however, the limb assumes a position of outward rotation and extension 
at the hip-joint, while in posterior dislocation of the head of the femur 
the limb lies in inward rotation with flexion at the hip ; and in fracture 
of the acetabular rim, the trochanter is relatively nearer the anterior 
superior spine of the ilium than it is in this dislocation. 

Fractures of the crest of the ilium or its anterior superior spine are 
readily recognized by the abnormal displacement and mobility of frag- 
ments, and the situation of pain, tenderness, ecchymosis, and crepitus. 

Complications. — The real gravity of fractures of the pelvis is due, as 
a rule, not to the damage done to pelvic bones themselves but to the injury 
to the pelvic contents which so frequently accompanies these fractures. 
The chief complications of pelvic fractures are injury to the bladder and 
urethra, the rectum, the vagina, the iliac vessels, the vesical and pudendal 
vessels, the sacral nerves, and the intestines. 

Lesions of the bladder may be the result of the force producing the 
fracture of the pelvis, particularly if the bladder is distended with urine 
at the time of fracture, or may be caused by its puncture by sharp frag- 
ments of bone. When rupture of the bladder is due to direct force and 
is accompanied by fracture of the pelvis, the bony lesion will usually be 
in the pubic rami, consist of a separation of the symphysis pubis, or be 
situated in the sacrum or the acetabulum. Primary ruptures of the blad- 
der are generally intraperitoneal, while secondary rupture, from perfora- 



FRACTUEES OF THE PELVIS 



499 



tion by sharp fragments of bone, are usually extraperitoneal. Bartel's 
statistics, based on 149 cases of bladder injury associated with fracture 
of the pelvic bones, shows the pubes to have been the seat of fracture 
in 31 instances and separation of the symphysis in 22 instances. 

Injuries to the urethra associated with fracture of the pelvis may 
be the result of direct violence, as in a fall upon the perineum with the 
thighs separated. Such causation of injuries to the urethra from asso- 
ciated fractures are, however, rare. Lacerations are more generally 
seen accompanying fracture in which the force has been applied from 
side to side, or anteroposteriorly. The lesion usually occurs in the mem- 




Fig. 583. — Drawing to show rupture of bladder and urethra compli- 
cating fracture of the pelvis, (a) extra- and intraperitoneal rupture 
of the bladder with extravasation of blood into space of Retzius and 
between coils of intestine at (c) ; (b) rupture of the urethra anterior 
to the triangular ligament will give extravasation of blood and urine 
into penis, scrotum, and superficial abdominal tissues as shown by 
dotted line. 



branous portion of the urethra. The urethra may be completely or incom- 
pletely torn across, and may be separated for a considerable distance from 
the surrounding soft parts. The most frequent lesions of the pelvis caus- 
ing accompanying injury to the urethra are fractures of the descending 
ramus of the pubes near the symphysis and of the ascending ramus of the 
ischium. The fragments of bone may tear the urethra by compression 
or laceration, or the injury may be the result of displacement of the trian- 
gular ligament inward with the fragment of bone (Fig. 583). 

Injuries to the other pelvic contents are generally the result of tearing 
or crushing by displaced fragments of bone. The blood-vessels most 
commonly injured are the common iliac, the external iliac, the gluteal, 



500 TREATISE OX FRACTURES 

the internal pudic, and the obturator arteries and veins. Lesions of the 
vagina and rectum are due to piercing of these structures by sharp frag- 
ments of bone. The nerves most frequently involved are the obturator, 
the sciatic nerves, and the sacral plexus. 

The symptoms of rupture of the bladder or urethra are difficulty of 
urination, hematuria or entire absence of any escape of urine, though the 
desire to empty the bladder may be urgent. In rupture of the urethra 
blood may trickle from the meatus. Bloody urine obtained by catheteriza- 
tion is always suggestive of rupture of bladder or urethra. Inquiry 
should always be made as to urination and when the bladder was last 
emptied before injury, if there is any lesion of the pelvis suspected. 

In rupture of the urethra the patient may be able to urinate, but 
the act is accompanied by marked pain and the urine will contain blood. 
The amount of urine will generally be small and will contain small 
amounts of coagulated or liquid blood. In suspected cases of rupture 
of the urethra or bladder, a metal catheter, No. 21 French, should be 
carefully introduced into the urethra. If it stops at the membranous 
urethra, and if on withdrawal the tip and eye are covered with blood, 
positive evidence of rupture is present. If the catheter passes into the 
bladder even after several failures and normal urine is obtained, but in 
addition there is trickling of blood from the meatus before catheterization 
and afterward, the evidence points to incomplete rupture of the urethra. 

In extraperitoneal rupture of the bladder there will be no difficulty 
in introducing the catheter into the bladder, but catheterization will show 
bloody urine. In intraperitoneal rupture, catheterization of the bladder 
will produce at first only a very small amount of bloody urine or at times 
only blood. Upon further introduction an elastic resistance will be felt 
which is the collapsed bladder wall. Possibly by deft manipulation the tip 
of the catheter may be introduced into the opening into the peritoneal 
cavity, when blood and urine will be obtained, if sufficient time has elapsed 
since the injury for their accumulation. This latter procedure is 
not advocated. 

After twenty-four hours additional symptoms will be present. In 
rupture of the bulbous portion of the urethra there will be possibly swell- 
ing of the scrotum and penis due to urinary extravasation. Infiltration 
above the symphysis and into the groins, and dulness of the lower part 
of the abdomen are indicative either of rupture of the urethra posterior 
to the triangular ligament or of extraperitoneal rupture of the bladder. 
In intraperitoneal rupture of the bladder there will be the symptoms of a 
rapidly increasing and severe type of peritonitis. Diagnosis of intraperi- 
toneal rupture of the bladder is frequently not made until too late to save 
the life of the patient. 

In a careful survey of the symptoms presented in suspected rupture 
of the urethra or bladder one should bear in mind that dysuria or anuria 
may result from contusion of the abdominal wall or severe concussion 
of the pelvis, producing paralysis of detrusor vesica? muscle. 



fbactub.es of THE PELVIS 501 

Prognosis. — The prognosis of fracture of the pelvis depends to a 
great degree upon the site of fracture and the presence or absence of 
injury to the pelvic contents. In uncomplicated fractures the prognosis 
is always favorable so far as life is concerned. There is required in 
ordinary cases from six to eight weeks for union to' take place, although 
the patient usually is incapacitated for a considerable time, depending 
to a great degree upon the region of fracture. Fractures involving the 
acetabulum, double vertical fractures of the pelvis, fractures of the 
sacrum, and those in the region of the- sacroiliac joint, as a rule, require 
a long time before convalescence is complete ; and in many instances the 
working power of the individual is permanently diminished. In fractures 
of the acetabulum permanent disability is often likely on account of imme- 
diate limitation of the range of the hip- joint and the possibility of the 
future development of arthritic changes due to excessive callus. In 
fractures about the sacro-iliac joint convalescence may be prolonged 
several years due to nerve pressure from fragments and callus, Coccy- 
godynia is a usual sequel of fracture of the coccyx. 

Fractures of the pelvis with permanent displacement of fragments 
may, in the female, be followed by difficult labor in subsequent childbirths. 

The most frequent complications of fracture of the pelvis are in- 
juries to the bladder and urethra. When present they greatly diminish 
the likelihood of a favorable prognosis. Intraperitoneal rupture of the 
bladder is followed by a septic peritonitis, unless prompt cceliotomy and 
suture of the bladder are performed. Extraperitoneal rupture of the 
bladder or rupture of the urethra is followed by urinary extravasation, and 
unless immediate repair is done, necrosis and suppuration of the soft 
parts occur. When perineal section is done for rupture of the urethra, 
there may be persistent urinary fistula or stricture resulting. Doctor 
Roberts has seen death from perforation of a duodenal ulcer, secondary 
to pelvic suppuration in front of the bladder, after fracture of the pelvis 
with laceration of the urinary bladder. 

Injury to blood-vessels may result in rapid and fatal hemorrhage 
or in subperitoneal haematoma, depending upon the vessel injured and 
whether the peritoneum is also torn. Aneurism of the injured vessel 
may develop. 

Injury to nerves may be followed by persistent motor paralysis, 
anaesthesia, or neuralgia. 

Treatment. — The treatment of fractures of the pelvic bones varies 
with the location of the injury; but in all the severer forms of fracture 
a catheter should be introduced at once in order to prove or disprove 
a laceration of the urethra. If such a tear exists, its presence requires 
prompt incision through the perineum down to the urethral wound, so that 
an extensive burrowing infiltration of urine may be forestalled by provid- 
ing drainage to the surface of the perineum. If the catheter finds its 
way into the bladder beyond what is evidently a small urethral wound, it 



502 



TREATISE ON FRACTURES 



may be permitted to remain, and the perineal incision omitted or post- 
poned. It will often be safer, however, to make a median cut down 
to the torn urethra to give exit for the leaking urine. The neck of the 
bladder need not be incised unless that organ itself is ruptured. After 
the perineal cut has been made the treatment is that required by an 
external urethrotomy for stricture; which is the occasional passage of a 
steel bougee. Cases may arise in which immediate suture of the urethra 
might be advisable with the retention of a rubber catheter through the 
urethra to drain the bladder. On account of the probability of rupture 




Fig. 584. 



-Application of circular adhesive plaster swathe in fracture of the pelvis. Protection 
of the supra-pubic hair space by a layer of sheet-wadding. 




FlG. 585. — Completed adhesive plaster swathe for fracture of the pelvis 



of urethra or bladder, the patient should be warned not to empty a full 
bladder until the surgeon has tested the integrity of these organs. Shock 
must be treated if occasioned by the pelvic fracture or coincident injury 
in other regions of the body. The treatment of fractures of the pelvic 
bones includes reduction of fragments when possible, maintenance of frag- 
ments in their normal position until union occurs, and the treatment of 
attendant shock and the other complications present. 

In reduction of displaced fragments, violent manipulations should 
be avoided, as they tend to increase shock and at times increase the extent 
of visceral injury. Careful manipulations, made through the rectum or 
vagina, aided by traction applied to the leg and thigh, may reduce dis- 
placed fragments of bone. In fractures of the rim of the acetabulum, 
double vertical fractures involving the entire pelvic rim, and in fractures 
of the acetabulum with perforation of the head of the femur through 
the acetabulum into the pelvis, reduction should be first accomplished; 
then the foot of the bed should be elevated for countertraction and a Buck 



FRACTURES OF THE PELVIS 503 

traction apparatus applied to the leg and thigh with sufficient weights 
(15 to 20 lb.) to maintain reduction. In fractures of the rami of the 
pubes or ischium, of the sacrum, in fractures in the region of the sacro- 
iliac synchondrosis, and in separations of the symphysis pubis, the patient 
should be placed flat on the back, with knees and thighs partially flexed 
by a pillow under the knees, and support to the pelvis be made by en- 
circling bands of firm muslin or adhesive plaster strapping (Figs. 584 
and 585). A firm swathe of strong muslin supplied with straps and 
buckles to' keep it tight around the pelvis and trochanter regions may 
be satisfactory. In some instances immobilization may best be maintained 
by the use of a gypsum case applied around the entire pelvis, from a point 
above the crest of the ilium to below the trochanters. The patient should 
not be allowed to get out of bed for eight or ten weeks or put strain on 
the fractured region by walking until the lapse of several weeks more. 
The severity of the injury and its location have an important bearing 
on this question, which must be settled after due consideration. In some 
cases reduction of fragments may be further accomplished by the use of 
packing in the rectum, or vaginal packing in women. This rectal support, 
however, should be carefully applied, and changed at least every other 
day ; the packing should have in its centre a rubber tube to facilitate the 
escape of flatus. 

In fractures of the crest of the ilium the encircling bandage should 
not be used, as it tends to increase the deformity. Support in this form 
of fracture is best obtained by the use of properly applied sand-bags. 
In perforating fractures of the acetabulum, with the head of the femur 
in the pelvic cavity, lateral traction outward on the upper part of the 
thigh should be used in addition to countertraction and the Buck traction 
apparatus. Fractures of the anterior superior spine of the ilium are 
best treated by flexion of the hip and leg and the use of an encircling 
gypsum case. The separated fragment may be held in position by subcu- 
taneous nailing with a wire nail or screw. Fractures of the tuberosity 
of the ischium should be treated by flexion of the leg on the thigh and by 
extension of the thigh at the hip so as to relax the ham-string muscles. 
Fractures of the coccyx are probably best treated by excision of the ter- 
minal fragment of the coccyx. 

When intraperitoneal or extraperitoneal rupture of the bladder is 
present, exploratory laparotomy should be performed. In intraperi- 
toneal rupture a vertical incision should be made in the median line 
through the abdominal wall, the pelvic cavity cleansed with moist sponges, 
and the rent in the bladder closed by two layers of interrupted Lembert 
sutures, the inner layer being of chromic catgut, the outer layer of silk. 
The abdominal wound should then be closed with a cigarette drain placed 
in the pelvic cul-de-sac. Catheterization should be; performed every eight 
hours afterward for at least ten days. In extraperitoneal rupture ex- 
posure is best obtained by a transverse suprapubic incision, and the tear. 



504 TEEATISE OX FRACTUBES 

when found, should be closed in the same manner as described above for 
intraperitoneal rupture. The after-treatment should be the same. Down- 
ward drainage through the perineal structures or through-and-through 
drainage by tube from the space back of the pubes to the perineum will 
often offer valuable aid in averting sepsis from deep infiltration of urine 
and septic fluids. 

The tests for establishing intraperitoneal rupture of the bladder are 
at times fallacious. It may be safer to make an opening in the median 
line of the lower abdomen and look into the pelvis or examine with a 
sterilized gloved finger thrust through a small incision than to delay till 
the advent of peritonitis jeopardizes the patient's life. 

To obtain success in the presence of these two complications, operative 
interference should be performed within the first twenty-four hours. In 
rupture of the urethra, perineal section should be done as soon as shock 
has disappeared. The proximal end of the torn urethra should be sought 
for, and when found a male catheter should be passed through the 
urethra from the external meatus to the bladder. When possible the two 
torn portions of the urethra should be united by chromic catgut and 
the perineal wound packed. Otherwise a free exit should be left for 
drainage of urine through the perineal wound. When the proximal end 
cannot be found, a suprapubic cystotomy should be performed and retro- 
grade catheterization done. The catheter should be maintained in the 
urethra for ten days to two weeks, and after this time careful dilatation 
with sounds should be made to prevent the occurrence of stricture in 
the urethra. 



CHAPTER XXI 



FRACTURES OF THE FEMUR 

Anatomy. — The femur (Fig. 587) is the largest of the long bones. 
It articulates with the innominate bone above and the tibia below. It 
consists of an upper extremity, a shaft, and a lower extremity. 

The upper extremity is divided into the head, the neck, and the 
greater and lesser trochanters. The head extends inward and upward, 
surmounting the neck, and consists of about two-thirds of a sphere. It 
is covered with fibro-cartilage, excepting at the attachment of the intra- 
articular round ligament just below and to the inner side of its centre. 
The neck,- shaped like an oblique truncated cylinder, is the constricted 
portion between the head and the shaft, and forms an obtuse angle with 




Fig. 586. — Ossification of innominate bone: (A) at third fcetal month; (B) at birth; (C) during first year; 

(D) at six years; (E) at about fifteen years, (a) chief centre for ilium; (b) chief centre for ischium; (c) for 

pubes; (d) for tuberosity of ischium; (e) for iliac crest; {J) for anterior inferior spine. 

the shaft of about 120 degrees in the adult. This varies during life 
from 160 degrees at birth to no degrees later in life. The great trochan- 
ter is the upper external portion of the shaft of the femur at its junction, 
with the neck. The small trochanter is a projection at the junction of 
the inner and posterior surface of the shaft of the femur opposite the 
great trochanter. Between the two trochanters run two ridges called the 
intertrochanteric lines. The posterior line is much more prominent than 
the anterior. 

There are separate epiphyseal centres for the head and the greater 
and the less trochanters, while the condyles of the lower extremity have 
a common epiphysis. The time for union for the great trochanter is the 
eighteenth year, for the small trochanter the seventeenth year, and for the 
head the eighteenth year. The condylar epiphysis unites with the shaft 
about the eighteenth or twentieth year. The femurs bear the entire weight 

505 



506 



TREATISE ON FKACTURES 



of the body in the upright position. The weakest portion of the bone, 
because of its structure and position, is the neck. It, however, is specially 
strengthened, not only by its shape, but also by the internal construction 
of the spongy structure, which is arranged with trabecular to bear pressure 
and tension in the definite lines needed. The head receives its blood supply 
through an artery in the round ligament and through the circulation in 
the cancellated structure. In later years the vessels in the ligament dis- 
appear almost entirely, so that the nutrition of the head is dependent upon 
the blood supply from the spongy tissue of the neck. 



Head 

Greater trochanter— 7 
Superior cervical tubercle 



Spiral line 



Shaft 



Patellar surface 
External condyle 




Fossa for round ligament 



Lesser trochanter 



Adductor tubercle 



Internal condyle 



Fig. 587. — Right femur, anterior view. 

The shaft of the femur is arched convexly anteriorly, is nearly 
cylindrical, and toward its lower end, becoming broader, presents a three- 
sided prism with three surfaces, two lateral and one ventral. Posteriorly 
is seen the rough longitudinal ridge, the linea aspera, which serves to 
strengthen the arch of the shaft and gives attachment to muscles. This 
crest or ridge divides below into the internal and external condylar ridges. 

The lower extremity of the femur is broad and consists of the two 
masses of bone, the internal and the external condyles. These are more 
prominent posteriorly and are separated by the deep intercondylar notch, 



FKACTUKES OF THE FEMUR 



507 



Obturator interims and gemelli 



Pyriformis' 



Gluteus medius —f 
Greater trochanter 4 




%m 



Vastus externi 



Attachment of ligamentum teres 
Edge of articular surface 



"Anterior intertrochanteric line 



h ;~j Lesser trochanter and psoas muscle 



Crureus- 



Fig. 588. — Anterior view of the upper end of the femur with muscular attachments. 



Attachment of 
the ligamentum teres t), 



Edge of articular surface — y*T 



Posterior intertrochanteric line -X— ~ 



Lesser trochanter 




Gluteus medius 
Greater trochanter 
Quadratus femoris 



Psoas and iliacus 
Pectineus 

Gluteus maximus 
Vastus internus 

Linea aspera 



Adductor magnus 
Vastus externus 
Adductor brevis 

Adductor longus 



FlG. 589. — Posterior view of the upper end of the femur with muscular attachments. 

while anteriorly they are united by the trochlear or articular surface of 
the patella. Upon each of the condyles there is a prominence on the 
lateral surface, the internal epicondyle and the external epicondyle. 



508 



TREATISE OX FBACTURES 



The hip-joint is the articulation between the acetabulum and the 
upper end of the femur. Its ligaments consist of the glenoidal or coty- 
loid ligament, which is a circular nbro-cartilage deepening the acetabular 
cavity, the round ligament, or ligamentum teres, inserted in the head of 
the femur, and the capsular ligament attached to the outer surface of the 
glenoid ligament, which surrounds the neck of the femur, excepting a 
small part posteriorly. In addition are the three accessory ligaments, the 
iliofemoral or the inverted Y ligament, which strengthens the capsule, the 
pubocapsular, and the ischiocapsular ligaments. The knee-joint is the 
articulation between the condylar surface of the femur and the tube- 
rosities of the tibia below and the trochlear surface of the condyles and the 




Fig. 590. — Landmarks on front 
of pelvis, showing by X ante- 
riorjand superior spines of ilium, 
spine of pubes, and by line the 
location of Poupart's ligament. 




Fig. 591. — The anterior superior spines of ilium 
may be difficult to palpate and mark in very 
fat patients. They appear to be higher than 
would be expected. The surgeon may be obliged 
to lift the pendulous abdomen to determine 
position of bony points. 



posterior surface of the patella in front. Upon the upper articular facets 
of the tibia are two menisci, called the internal and external semilunar 
fibro-cartilages. The ligaments of the knee-joint are : the internal lateral 
ligament, the external lateral ligaments, the posterior ligaments, the liga- 
ment of the patella, the capsular ligament, the synovial or alar ligaments, 
the anterior crucial ligament, and the posterior crucial ligament. 

Surface Markings. — The principal landmarks to be remembered in 
fractures of the femur are the anterior spine of the ilium, the spine of the 
pubes, the tuberosity of the ischium, the great trochanter of the femur, 
the umbilicus, the patella, and the internal malleolus. These points are 



FRACTURES OF THE FEMUR 



509 



of value in determining shortening of the bones of the thigh and leg. 
On the outside of the thigh, about four inches below and posterior to the 
anterior superior spine of the ilium, will be found a marked prominence 
just below a depression; it is the great trochanter of the femur. The 
relations of this trochanter to other landmarks are of great importance, 
for they are valuable in reaching a diagnosis in cases of fracture 
and dislocation. 

A number of aids are in use for determining the existence of fracture 
of the neck of the femur. The most important of these are the relation 
of the trochanter of the injured limb to the Roser-Nelaton line and the 
Bryant triangle. These topographical markings are used particularly 




Fig. 592. — Bony landmarks (posterior). Thumbs are pressed against 
tuberosities of ischium; fingers on greater trochanters of femurs. Pos- 
terior superior spine of ilium. (Modified from Cotton.) 



in determining the presence or absence of elevation of the great trochanter 
on the injured side. The Roser-Nelaton line (Figs. 593 and 594) is a 
line drawn from the anterior superior spine of the ilium to the tip of 
the tuberosity of the ischium. Normally the upper border of the great 
trochanter should touch this line, and this relation is not disturbed by 
flexion and extension of the thigh. Comparison of the two sides will 
usually show a displacement upward of the trochanter in fracture of the 
neck of the femur. The two sides must be examined with the two limbs 
perfectly parallel to each other and at right angle to a line drawn across 
the top of the pelvis, either at the level of the crests of the ilia or from 
one anterior superior spinous process to the other (Fig. 595). Abduction 
or adduction of either side will alter the results and render the test 



510 



TREATISE ON FRACTURES 



valueless. Bryant's triangle (Figs. 593 and 594) is formed by dropping 
vertically a line from the anterior superior spine of the ilium to the bed 
or table on which the patient lies supine ; a second line is drawn at right 

angle to this line, running in the axis 
of the thigh to the great trochanter 
to this primary line, and a third line 
is drawn from the anterior superior 
spine of the ilium to the great trochan- 
ter, thus forming a triangle. In frac- 
tures of the neck of the femur the 
second line is found to be shortened 
in comparison with that of the sound 
side (Fig. 603a). 

Relaxation of the fascia lata as a 
test or proof of shortening due to frac- 
ture of the femur was first suggested 
by Allis. This relaxation is best ob- 
served between the crests of the ilium 
and the great trochanter, and also 
above the outer condyle of the femur 
(Fig. 597). 

Another measurement used to 1 de- 
termine shortening of the leg from 
fracture of the femur is that between 
the anterior superior spine of the ilium 
and the internal malleolus (Fig. 598). 
Comparison with the sound side will determine the presence of shorten- 
ing in fractures of the femur or of the bones of the leg (Fig. 599). 
Measurement between the anterior spine of the ilium and the adductor 




Fig. 593. — View of outer surface of the bones 

of the hip showing Roser-Nelaton line (a-d); 

Bryant's triangle ^abc) ; iliotrochanteric line \a-c) 

and the iliotrochanteric angle (bac). (Davis.) 




Fig. 594. — Outer surface of right hip and thigh showing Roser-Nelaton line and Bryant's triangle. 



tubercle is at times used to demonstrate shortening in fractures of the 
femur. When making these measurements, the patient should be placed 
on a flat table and care be taken to place the lower limbs exactly parallel 
to each other and at right angle with the transverse axis of the pelvis 
or a line drawn through the acetabula. It must be recollected that unin- 



FEACTUEES OF THE FEMUR 



511 



jured femurs may be asymmetrical in length, and that usually the surgeon 
has no information whether the longer or shorter femur has been broken. 
This has been proved by measuring 
the bones of skeletons in which 
there has been no injury prior to 
death. The tibia on one side may 
be longer than that of the other leg, 
therefore a difference in the length 
of legs after a fracture may be due 
not to a broken femur but to a nor- 
mally short tibia. These known 
anatomical variations must be 
reckoned with in investigating pos- 
sible fractures. 

The shaft of the femur is well 
covered by muscles, so that the 
shaft can be only indefinitely felt 
with the fingers. At the lower end 
of the femur the internal and ex- 
ternal condyles may be readily 
palpated, as well as the adduc- 
tor tubercle. 

Fig. 596. 





Fig. 595. — In making measurements from the anterior 
superior spine of the ilium to the internal malleolus to 
determine shortening on the injured side, the two 
lower limbs should be parallel to each other and at 
right angle to a line drawn through the anterior 
superior spines, as in A. If tilting of the pelvis is 
present, as in B, incorrect conclusions will be made. 



Fig. 597. 




Fig. 596. — To demonstrate elevation of the great trochanter in fracture of the neck of the femur. Not 
only is there elevation of the trochanter but it is in closer contact with the upper rim of the acetabulum. 

Dotted line shows normal position. 
Fig. 597. — Showing relaxation of the fascia lata which occurs in fracture of the femur. Allis method of 

determining the same. 



512 



TREATISE ON FRACTURES 

Fractures of the Upper End of the Femur 



Fractures of the Head of the Femur. — This injury is extremely rare 
(Fig. 600). The reported cases occur not as independent fractures but 
in conjunction with dislocation of the femoral head, especially of dislo- 
cations from direct thrust, says Cotton. They partake of the nature of 




J 

Fig. 598. — Method of measuring from the anterior superior spine of the ilium to the internal malleolus. 
A flexible steel tape should be used. 

a compression fracture, and are due to such trauma as a direct fall upon 
the trochanter or being run over by a heavy wagon. A case reported by 
Riedel showed longitudinal splitting of the head and neck. The symp- 
toms were shortening to about two 
inches, inward rotation, flexion, 
and indistinct crepitus. The treat- 
ment in this case consisted of ex- 
cision of the upper fragment with 
reposition of the remainder of the 
head into the acetabular cavity. 
Recovery followed with ankylosis 
and shortening of 2 cm. Other 
cases are reported by Braun and 
by Stimson. It is possible that nail- 
ing through the great trochanter 
and neck might be available. 

Fractures of the Neck of the 

Fig. 599. — Showing the shortening which occurs in _ . . , r 

fracture of the neck or of the shaft of the femur as temur. 1 mctUreS 01 the nCCK Ot 

compared with the well side. ■ N 

the femur (Figs, ooia-ooic) 
are observed during all decades of life. In children rare, in early adult 
life they are fairly frequent, but the great majority are found in late 
adult life, particularly after the age of fifty-five years. Recent investiga- 
tions based upon radiographic examination have shown a comparative 
frequency of these fractures during childhood. Before the use of the 
Rontgen ray these usually were considered to be contusions of the hip 





or epiphyseal separations of the femoral head. 



Haldenwang and Whit- 



FBACTFBES OF THE FEMUE 



513 



man's observations on this subject have been very enlightening. Halden- 
wang collected a series of 25 cases occurring between the ages of one 
and eighteen years ; and of these 23 were fractures of the femoral neck. 
Seven were found in children ten years of age or younger, and 17 were 
between ten and eighteen years. Of them 15 were — 

observed in females. In the majority the fracture 
was at the base of the neck, a few were close to 
the head, and the remainder were intermediate 
fractures. All excepting six were only recognized 
long after the injury, when an operation was about 
to be performed for the resultant coxa vara. Cer- 
vical fracture is, however, one essentially of late 
adult life, and is more common in women than in 
men. It constitutes one-third of all fractures 
occurring in persons over seventy years. 

Etiology. — Very few patients are able to tell 
just how their femurs have been broken. Experiments have been made 
which show that fractures of the femoral neck may occur from a variety 
of forces. They may be produced by direct force applied to the trochanter, 




Fig. 600. 

tions of. 



•Femoral head, por- 
Intracapsular frac- 
ture, from a case of seven 
years' standing. (Mutter 
Museum, No. 1397.0035.) 



Fig. 6oic. 



Fig. 601&. 



Fig. 6oic. 




Fig. 601a. — Femur, intracapsular fracture of the neck; ununited. The line of fracture is close to the 
head and is transverse. (Mutter Museum, No. 1397.003.) 
Fig. 6016. — Femur, right: Fracture of the base of the neck. (Mutter Museum, No. 1397.0255.) 
Fig. 60 ic. — Femur, upper third of: Intracapsular fracture of the neck; ununited. The neck of the 
femur has been absorbed, allowing the head of the bone to sink so as to nearly touch the trochanter 
minor. The fracture is wholly within the capsule. There is no bony union. (Mutter Museum, 

No. 1397.004.) 



by a blow on the knee, by extreme abduction or by undue hyperextension. 
Some authorities contend that fractures of the neck are in some instances 
the result of strain exerted through the ligaments when the limb is in an 
extreme position, and that the fall is the result of the fracture and not 
the fracture the result of the fall. In the majority of cases, however, the 
33 



514 



TREATISE OX FRACTURES 



fracture is probably the result of a misstep, a fall to the ground while 
walking, or a slight jar. In the very young, moderate forms of violence 
may be the exciting cause of these cervical fractures. Those observed 
in early adult life are generally the result of more extreme violence, such 
as a fall upon the trochanter, or upon the buttocks. In the aged little 
force is required to cause the injury. Often a misstep and the subsequent 
effort to regain one's balance may be the only form of violence to which 
the femur has been subjected. 




Fig. 602. 



-Fracture of the neck of the femur. (Collosubcapital junction of the head and 
the neck.) 



PVactures by muscular action are occasionally observed in cases in 
which the capsule and Y-ligament are unduly stretched by the muscu- 
lar pull. 

The contributing cause of fracture, in persons over fifty years of 
age, is the change which takes place in the composition of the bones of 
the entire skeleton. In the neck of the femur these changes are particu- 
larly important, in that they greatly lessen the strength of the neck of 
the femur, which depends upon its anatomical construction to support the 



FRACTURES OF THE FEMUR 515 

whole weight of the body in walking and to repel all sudden strains and 
stresses placed upon it. 

After the fiftieth year there occurs an eccentric atrophy of bone. The 
cortex of the neck of the femur becomes thinner, and the lamelke of the 
spongy interior are to a great measure absorbed and replaced by large 
cavities containing yellow bone-marrow. This rarefaction of osseous 
tissue, with the consequent loss of strength, is a much more potent factor 
in the frequent occurrence of fractures of the neck of the femur than 
the changes of angle which occur between the shaft and neck with advanc- 
ing life. This degenerative change is the predisposing cause which per- 
mits slight injuries to have such disastrous results. 

Varieties. — Classification of fractures of the femoral neck, based upon 
radiographic findings given by Plagemann is : ( i ) fractures collosubeapi- 
tal (Fig. 602); (2) fractures collo-intermediate (Figs. 6oia-6oir) (the 
earlier fractures of the neck of the femur) ; (3) fractures collo-inter- 
trochanteric (Fig. 604a) (after Kocher ) or basal fractures of neck of 
femur (after Konig) without accompanying fracture of the trochanteric 
region; (4) fractures collotrochanteric (Figs. 604 and 605a and 605&). 

The first, or collosubcapital, form of fracture is intracapsular, located 
near the head of the bone, with an irregular fracture line running trans- 
verse or slightly oblique. 

The second, or collo-intermediate, the so-called mixed fracture of 
the neck of the femur, has a fracture line irregularly oblique, running 
through the middle of the femoral neck. This fracture is similar to the 
partially intra- and partially extracapsular fracture of the earlier classifi- 
cation of mixed fractures. On account of the lower insertion of the joint 
capsule in front than behind, the line may be intracapsular in front and 
extracapsular behind. 

The third, the fracture collo-intertrochanteric (Kocher), has a line 
running through the base of the neck of the femur along the intertro- 
chanteric line, ending near the lesser trochanter, without an accompany- 
ing fracture of the trochanteric region. 

The fourth, the so-called fracture collotrochanteric, has a fracture 
line which runs through the base of the femoral neck on one side and 
through the region of the trochanter on the other side, and usually takes 
the form of the letter T, K, or L. In this form there is at the same time 
a complete or partial breaking off of both trochanters, combined with 
more or less numerous separate fissures, running into the diaphysis of 
the femur. 

In addition to those of the above classification there are fractures 
which show other than the usual characteristics ; but in the main, the 
classification given above covers the varieties as well as is possible. The 
exceptions to these four varieties may be looked upon as irregular varie- 
ties. Most fractures will be found to come under one of two heads — 
fractures of the narrow part of the neck, and fractures at the base 



516 



TREATISE ON FRACTURES 





FBACTUKES OF THE FEMUR 

Fig. 604a. Fig. 6046. 



517 




/ 




Fig. 604a. — Fracture of the neck of the femur. (CoHo-intertrochanteric. Base of the neck.) 
Fig. 6046. — See Figs. 605a and 605b. 



Fig. 605a. 



Fig. 6056. 




Figs. 605a and 6056. — Fracture of the neck of the femur. (Collotrochanteric. Involving both neck 

and portion of trochanters.) 

of the neck. The older terms, intracapsular and extracapsular, should 
be discarded. 

Impaction and fixation of fragments at the time of the injury is 
very frequent in fractures of the base of the neck and not infrequent 
in those of the subcapital variety. When impaction occurs, the resulting 
e version or inversion depends upon whether the posterior part or the an- 
terior part of the neck suffers greater destruction. When there is eversion 



518 



TEEATISE OX FBACTUKES 



present, destruction of the posterior wall of the neck is the greater, and 
when inversion occurs greater destruction of the anterior part of the neck is 
present. The presence of eversion or inversion is due to the direction 
of the fracturing forces and the form of rotation present at the time of 
fracture. Nearly all fractures of femoral neck, if not disturbed by 
handling, will probably be found to be impacted or the fragments at 
least entangled. 

When the fracture line occupies the apex of the neck there is great 
liability of interference with the blood supply of 
the head. Usually there remains some blood sup- 
ply through the round ligament or through por- 
tions of untorn capsule and periosteum, or from 
both sources. In fractures at the base of the neck 
interference with the blood supply is not so liable 
to take place, as the line of fracture is partially 
without the capsule of the joint. Impaction of 
fragments is more frequently present as the frac- 
ture line approaches the trochanters. Fractures 
at the apex of the neck show frequently absence 
of impaction or incomplete impaction. Fractures 
toward the base are generally impacted. This 
impaction may be complete or incomplete. 

In fractures in which impaction is complete 
the upper fragment of the neck is driven into the 
trochanteric fragments, which are usually twisted 
backward, and with the shaft of the femur rotated 
outward. The angle of the shaft and neck 
approaches more nearly a right angle and the dis- 
tance between the trochanters and head is less- 
ened. When impaction is incomplete it is due 
either to violent manipulation of the part or more 
frequently to the fact that it does not involve the 
entire circumference of the neck, so that only 
one side, generally the posterior part, and the 
upper fragment, is impacted into the trochanteric 
fragments. When impaction is absent, particu- 
larly in fractures at the base of the neck, the trochanteric fragment with 
the shaft is drawn upward, displaced backward, and rotated outward. 
This position is due to muscular pull and the weight of the extremity, 
which tends to rotate outward from its own weight when the patient is 
lying on his back. 

Symptoms. — Localization of the exact seat of fractures of the neck 
of the femur is almost impossible by clinical symptoms alone. This 
is due to the shortness of the fragment and its depth in the tissues. In 
cases of suspected fracture, and indeed in all injuries about the hip- joint 




Fig. 606. — In fracture of the 
femoral neck without impaction, 
shortening occurs and gravity 
everts the limb as the patient 
lies on his back. 



FBACTFBES OF THE FEMUR 



519 



that cause disability, radiographic examination should be made. It is 
only by adhering strictly to this rule that the exact variety of a fracture 
and the presence or absence of impaction may be determined. In a small 
number of cases radiographic examination will not be possible, on account 
of the age of the patient or other difficulty of transportation, and in these 
cases diagnosis must be made from the clinical symptoms. 

The symptoms of fracture of the neck of the femur are impairment of 
motion, muscular relaxation, false motion, eversion or inversion, shorten- 
ing, crepitus, pain, tenderness on pressure, swelling, ecchymosis. 

Impairment of Motion. — As a rule the patient is unable to lift the 
extremity from the bed or to bear the , _ -n 

weight of the body upon it. At times 
he is able to slightly elevate the thigh 
from the bed, particularly if he can 
obtain a purchase on the bed with the 
heel. Flexion of the thigh is at times 
possible when the thigh is in a position 
of abduction. Ability to raise the foot 
from the bed is usually impossible. 
When impaction of fragments is ab- 
sent, motor disability is more marked 
than in those cases where it is present. 
In some instances patients have been 
known to walk on the injured limb, 
but in these instances firm impaction 
was present. 

Muscular Relaxation. — With the 
shortening of the distance between the 
iliac crest and the great trochanter mus- 
cular relaxation takes place, particu- 
larly of the gluteals and of the tensor 
of the fascia of the thigh. This relaxa- 
tion is noted by the presence of an abnormal depression above the great 
trochanter, and above the outer condyle of the femur (Fig. 597). 

Cleemann has called attention to a wrinkling of the skin over the 
patellar ligament in fractures of the neck of the femur, which will be 
obliterated when extension is made. This is due to the same physical 
cause as the lessening of tension of the fascial sheath on the outside of 
the thigh, namely, the shortening of the length of the thigh bone by over- 
riding at the point of fracture. 

False Motion. — This is demonstrated by rotation of the thigh with 
one hand while the other hand is placed upon the great trochanter 
(Fig. 608). In impacted fractures of the neck of the femur this arc 
of rotation will be less than on the normal side and will be the arc of 
a circle whose radius is the distance from the line of fracture to the 




Fig. 607. — Muscular relations behind the hip- 
joint. The great gluteal and the middle gluteal 
(1 and i' and 2 and 2') muscles have been cut 
to show lower layer of muscles: — Small gluteal 
(3), sciatic nerve (4), head of femur (5), and 
quadrate muscle (6). 



520 



TREATISE ON FRACTURES 



surface of the trochanter. In unimpacted fracture the shortness of 
the arc of rotation will be even more marked; it is more evident the 
nearer the fracture is to the trochanter (Fig. 609). 

Eversion and Inversion. — An increased e version of an injured limb 
is usually pathognomonic of fracture. When a person lies on his back 




Fig. 608. — Showing method of determining false motion in fractures of the neck of the femur. One 

hand is placed upon the great trochanter while the other produces alternate inward and outward rotation 

of the thigh. Lessening of the arc of rotation will also be determined. 

both thighs are usually slightly everted by gravity. When the neck of 
a femur has been broken there is usually a slight degree of abduction and 
flexion at the hip, with marked eversion of the entire extremity. In im- 
pacted fractures the limb rests upon its outer side with the little toe almost 
touching the mattress and the heel is on a level with the hollow between 




Fig. 609. — Drawing to show why the arc of rotation is shortened in unimpacted fractures of the neck of 
the femur. In .4 the centre of rotation is at the acetabulum, while in B, C and D the centre of rotation 
is about the axis of the femoral shaft. In impacted fractures the centre of rotation is at the acetabulum, but 

the arc is less than normal. 

the internal malleolus and the tip of che calcaneum of the sound foot. 
In unimpacted fractures eversion is absolute and the limb is generally 
not flexed or abducted at the thigh. This eversion is due to the fact 
that crushing and impaction of the posterior portion of the neck are 
usually greater than involvement of the anterior part of the neck, and 
also by the fact that gravity is unresisted by the normal supporting 
agencies of the limb. 



FBACTUBES OF THE FEMUR 



521 




In a few instances inversion, which may be marked, is seen. This is 
usually due to impaction at the front of the fracture from the injury 
being the result of a blow on the back of the hip. In all cases com- 
parison with the uninjured limb should be made to determine whether 
eversion is apparent or real, whether the extent of possible e version is 
greater or less on the injured side, and whether the supposed fracture 
interferes with or increases toward rotation. Violent manipulation to 
determine false motion, eversion, or inversion is strongly condemned. 
It is often wiser to delay making a positive diagnosis than to break up 
impaction or tear the periosteum at the seat of fracture. 

Shortening. — Shortening is one of the most important diagnostic 
signs in fracture of the neck of 
the femur. It depends upon 
changes in the angle of the neck 
with the shaft and upon over- 
riding of fragments. In im- 
pacted fractures the shortening 
is usually less than one inch, 
while in unimpaeted fractures it 
may be from one and a half to 
three inches. . A primary small 
amount of shortening, occurring 
in an impacted fracture, chang- 
ing later to a great degree of 
shortening, indicates partial or 
complete abolition of impaction. 
Bardeleben states that in frac- 
tures of the narrow part of the 
neck within the capsule, longitu- 
dinal displacement is prevented 
by the action of the intact por- 
tion of the capsule or by the 
impingement of the upper 
fragment against the small trochanter 
the fragments are unlocked, the shortening increases. In taking measure- 
ments to determine the presence of shortening, attention should be paid 
to the normal differences which may normally exist in the same individual 
in the length of the two femurs and of the two tibias. A man may have 
legs of unequal length before the receipt of injury. 

The most trustworthy methods to determine the presence of shorten- 
ing due to fracture of the neck of the femur are: (i) Measurement of 
the distance from the anterior superior spine of the ilium to the tip of 
the internal malleolus (Fig. 598), on both sides. In fracture of the 
neck of the femur the distance between these two points will be less on 
the affected side. (2) The relation of the great trochanter to the Roser- 



, 



/ ; 



Fig. 610. — Anterior view of relations-of muscles to fracture 

of neck of femur. Psoas (i), iliacus (2), middle gluteal (3), 

internal obturator (4). 



Later, if the capsule yields or 



522 TEEATISE ON FRACTURES 

Nelaton line (Figs. 593 and 594). In fracture the great trochanter will 
be above this line. (3 ) Measurement by means of Bryant's triangle (Figs. 
593 and 594). In this test the distance from the tip of the great tro- 
chanter to the vertical line dropped from, the anterior superior spine of 
the ilium with the patient flat on his back will be less on the affected side. 
In making use of these three tests the patient should lie upon a firm, 
flat surface, such as a table, the two lower extremities parallel to each other 
and to the line of the spine and at right angles to a line drawn through the 
two anterior superior spines of the ilia. Shortening may also be deter- 
mined by the Allis and the Cleemann tests noted above. 

Crepitus. — Crepitation is an important symptom of fracture of the 
neck of the femur when it can be elicited. It is not obtainable in the 
presence of impaction of fragments, or in those cases of non-impaction 
where the fragments are overriding and cannot be brought into apposi- 
tion by traction. It should not be sought for, as a rule, because of the 
danger of separating impaction of fragments and tearing adherent bands 
of periosteum. When impaction is not present crepitus can generally 
be demonstrated by pressure back of the great trochanter or by traction 
with or without rotation. It may be simulated in manipulation by the 
rubbing of the outer fragments upon the ilium. Crepitus in unimpacted 
fractures may more readily be determined in fractures involving the base 
of the neck and trochanters than in those of the part of the neck close 
to the head. 

Pain. — In fractures of the neck of the femur pain is generally present. 
It is greater in fractures involving the base of the neck; and in these 
cases is generally at the outer and upper part of the hip, while in frac- 
tures of the neck the pain is generally in the inguinal region. Pain is 
increased by active or passive movements of the thigh. 

Tenderness. — Tenderness on pressure is generally localized outside 
of the femoral vessels. 

Swelling. — Localized swelling is generally present in all fractures of 
the neck of the femur. It is greater in fractures approaching the tro- 
chanteric region. The fold of the buttock is less pronounced than on 
the sound side. 

Ecchymosis. — Ecchymosis only appears after several days have 
elapsed, and it appears more constantly in proportion to the proximity 
of the fracture to the great trochanter. When the line of fracture is 
mainly within the joint capsule, the area of ecchymosis is limited to the 
groin below Poupart's ligamerit and inner surface of thigh. In fractures 
of the base of the neck, which are mostly or wholly outside of the joint 
capsule, the area of ecchymosis is limited generally to the trochanteric 
region, but it may be scattered over the outer surface of the thigh 
and buttock. 

Diagnosis. — In the presence of the above symptoms diagnosis is 
usually easy. Even when the symptoms are slight in character a positive 



FEACTFEES OF THE FEMFE 



523 



diagnosis of fracture of the neck of the femur generally may be made by 
careful examination without rough handling of the limb. An anaesthetic 
is not required and violent manipulations to determine crepitus should 
never be made. In practically all instances a radiographic examination 
will determine the presence and site of the fracture. When there is any 
doubt as to the existence of a fracture, it should be treated as such until 
an absolute diagnosis is made by the subse- 
quent history. A correct diagnosis of the 
site of the fracture may often be made by the 
clinical examination, if careful consideration 
is given the symptoms and physical signs. 
The exact line of break is not so important 
as some surgeons seem to think. The treat- 
ment does not vary much in the different 
varieties of fracture of the femoral neck. 

Fractures of the neck of the femur should 
be carefully differentiated from luxation of 
the hip (Fig. 611), unilateral fracture of the 
pelvis, and contusion of the hip. Fractures 
usually may be differentiated from posterior 
dislocations of the head of the femur by the 
presence of eversion in fracture. Inversion 
in fracture is rare, but present in the iliac and 
sciatic luxations of the head of the femur. 
When eversion occurs in fracture, the flexion, 
adduction, and fixation found in posterior 
luxations are absent; moreover, the head of 
the bone is not found on the dorsum of the 
ilium or sciatk notch as in posterior disloca- 
tion. In fracture with inversion, traction 
may break up the impaction, changing the 
inversion to eversion and correcting the short- 
ening, which it would not do in posterior dis- 
location. Dislocation is rare in the aged, but 
fracture is common as a result in injury. The 
symptoms already described and the X-ray FlG - 6n.— Anterior luxation of the 

.„ , . ... . J right hip-joint. Note tvpical attitude. 

Will reveal the Condition. apparent shortening, eversion of the 

Fractures with eversion may be mistaken 
for anterior dislocation of the head of the femur. The anterior dislo- 
cations are, however, rare and are accompanied by flattening of the 
trochanteric region, abduction and flexion of the thigh and the presence 
of an abnormal prominence at the site of the displaced head of the femur 
on the pubes or in the obturator foramen. In dislocations there is always 
marked limitation of passive motion, and the limit of possible mobility 
is always revealed by a sudden arrest of movement felt by the hand of 




524 TREATISE ON FRACTURES 

the examiner. The axis of the head of the femur and that of the inner 
surface of the internal condyle normally point always in the same direc- 
tion; attention to this fact will determine the position of the head of the 
bone in dislocation of the head of the femur. In fractures the normal 
parallelism of these two areas may be changed. 

Fracture of the femoral neck should be carefully diagnosticated from 
fracture of the pelvis. The fractures of the pelvis with which it may 
be confused are fracture of the rim of the acetabulum and fracture of 
the acetabulum with partial or complete penetration of the head of the 
femur through the acetabulum into the pelvic cavity. In these cases a 
careful examination of the patient and a radiogram will make clear 
the diagnosis. 

Fractures of the neck of the femur should be differentiated from 
contusion of the hip. In contusion there may be impairment of motion, 
elevation of the pelvis on the side affected, outward rotation and flexion 
of the thigh, severe pain, and at times muscular spasm. Fracture, how- 
ever, it is well to remember, often occurs in elderly people as a result 
of a moderate degree of violence, and instead of improvement taking 
place the functional condition becomes worse. In simple contusion a 
relatively severe degree of violence is present and the function of the 
part tends to improve after several days. In addition the symptoms of 
contusion generally are localized in the area injured. 

A recent fracture of the neck of the femur should be differentiated 
from a previous fracture, or from an arthritis deformans to which a local 
contusion has been added. Skiagraphy and the clinical circumstances will 
aid in the determination of the true character of the patient's disability. 

Fractures below the trochanters may be differentiated from those 
of the neck by the fact that rotation of the trochanter does not occur 
when the shaft of the femur is rotated by the surgeon, and the evidence 
that rotation of the shaft occurs upon its longitudinal axis. 

Prognosis. — Many fractures of the neck of the femur are observed 
in persons of advanced life. The problem is not so much to obtain perfect 
anatomical apposition of fragments and a perfect functional result as to 
prevent the development of conditions which, with confinement to bed 
and the incidental shock of the injury, may produce death. Many of 
the deaths in these cases are due to hypostatic pneumonia, to development 
of mental and physical shock which produces death in a few days, or 
to sepsis from extensive bed-sores. A few cases are undoubtedly due to 
fat embolism or to acute dilatation of the heart due to fatty degeneration. 
It is unquestionably true that close confinement to bed in the recumbent 
position, with cumbersome and fixed dressings for a long period, will tend 
toward hypostatic pneumonia, bed-sores, and fatty degeneration of the 
heart. Patients of the age in which this form of fracture is so common 
often do not take kindly to enforced immobilization in the recum- 
bent position. 



FEACTUEES OF THE FEMUR 525 

The problem in the aged in regard to union and subsequent function 
is an entirely different problem from that in cervical fracture in the young 
and robust. Impaction of fragments is the rule in the old, particularly 
in fractures occurring in the outer half of the neck. This impaction 
should seldom be broken up to obtain more satisfactory position of frag- 
ments. In these patients anatomical results may be imperfect, but aside 
from a moderate degree of shortening and an irregular period of dis- 
comfort and pain, the patients should be able to get about with a slight 
limp after a period of several weeks, or, at the worst, obliged to use a cane 
for partial support. Fractures occurring in the inner half of the neck 
are more liable to be unimpacted than those of the outer half. In these 
unimpacted cases of the inner half of the neck, bony union is the excep- 
tion; fibrous union, pseudarthrosis or complete atrophy of the inner 
half of the neck is perhaps the rule. Even in impaction of this region 
the impaction may be broken up by slight jarring, by the weight of the 
body, or by secondary necrosis. 

Non-impacted fractures of the outer half of the neck under appro- 
priate treatment should result favorably in firm, bony union, with a small 
amount of shortening and loss of function. Even when non-union occurs 
in unimpacted fractures of the neck, a fair amount of weight-bearing is 
possible and with the use of a cane a favorable degree of function often 
will be obtained. There are many fractures in middle life and earlier in 
which a proper restoration of the anatomical contour is desirable, and 
obtainable to a very great degree. Union in good position is to be sought 
sometimes even by operative fixation. 

Treatment. — There are two considerations in the treatment of frac- 
tures of the neck of the femur — the patient and the fracture itself. 
Fractures, whether impacted or not, induce a tendency in the aged 
patient to the development of hypostatic pneumonia, cardial degeneration, 
and bed-sores. Even those fractures which show no such untoward symp- 
toms, except perhaps an inability to remain constantly confined in bed, 
should be disregarded to a certain extent whenever fracture fixation 
threatens the general health of the patient. In such instances apparatus 
should be removed and the patient set up in bed or placed in a wheel- 
chair. In many instances, however, no such emergency arises even in 
the aged. 

In impacted fractures of the aged situated in the femoral neck close 
to its head, it is unwise to attempt forcible reduction to secure better 
reconstruction of the bone. These cases should be handled as carefully 
as possible, and if there are no contra-indications the patient should be 
placed upon a firm level mattress, the foot of the bed slightly elevated, 
and the leg immobilized either by sand-bags placed on both sides or by the 
application of a long external or a T-splint. If there is muscular twitch- 
ing, it is advisable to supplement this dressing by the application of a 
Buck traction apparatus with from three to six pounds fastened to the 



526 



TREATISE ON ERACTUBES 



stirrup (Fig. 612). This weight steadies the part and often gives con- 
siderable comfort. This dressing should be used for from four to eight 
weeks. It may be removed at this time and a short spica of plaster-of- 
Paris perhaps applied from the waist to mid-thigh, and the patient allowed 
upon crutches. In the aged it is better to remove all apparatus at the 
end of about five weeks and allow the patient to get up ; at first sitting up 
in bed a short time daily, later resting in a chair, and at the end of about 
ten weeks walking with crutches. Bed-sores in sacral region and at tip 
of heel must be averted by pads of oakum or other spongy material 
supplemented by frequent bathing and powdering the skin. 

Exception to the above rule in the treatment of impacted fractures 
is in cases occurring in early childhood or middle age, which, if left 



I 



L 




£ 







i 



6 



Fig. 612. — Method of applying Buck's traction apparatus. Adhesive plaster spreader to keep pressure 
from the malleoli, a padded posterior splint to keep the heel from the bed. This dressing should be 
supplemented by a Liston or T-splint or by sand-bags to steady extremity. Should have padding to 
protect malleoli from pressure between skin of ankle and traction straps. By greatly elevating pulley 
and changing direction of pull, traction may be made in line of upper fragment if it be elevated and 

rotated outward. 

uncorrected, may result in a deforming coxa vara with considerable sub- 
sequent deformity and loss of function. In these cases it is advisable, 
perhaps only after consultation with another surgeon, to correct the 
deformity under ether, place the part in extreme abduction and traction, 
and while in this corrected position to> apply a gypsum spica splint from 
chest to toes of the affected side after the method of Whitman. 

There are several methods of treatment for non-impacted fractures 
that may be used. The reader should bear in mind the fact that a very 
great majority of cervical fractures are impacted, or at least the fragments 
entangled. The loose fractures found in aged persons have in many 
instances probably been made non-impacted by rough handling or 
unwise effortsi to obtain crepitus in examinations to establish 



FEACTUEES OF THE FEMUE 



527 



a positive diagnosis. Such insistence upon crepitus being exhibited 
is unwise. To await opportunity for X-ray testimony is better 
surgery than to hastily break up the impaction and permit great 
upward displacement. The usual dressing used as a routine is Buck's 
traction apparatus with from twelve to thirty pounds' weight attached 
to the stirrup, elevation of the foot of the bed for countertraction, and 
lateral support by sand-bags, boxes of bricks or a T-splint. A long 
external straight splint extending from the axilla to below the foot may 
be used instead of the sand-bags. At times this may be supplemented by a 
posterior splint carefully padded, extending from the crease of the buttock 
to a point several inches above the heel. 

It is probably true that nearly all new fractures in those approaching 
old age are impacted or the fragments entangled by the breaking force. 
The non-entangled and non-impacted fractures seen in practice have 
often, it is believed, been made so by improper handling. 

A second form of dressing is the use of longitudinal traction with 




A b c o E 

Fig. 613. — Principles to be considered in Whitman's abduction method for the treatment of fractures of 
the neck of the femur. (.4) Normal range of abduction depends upon the angle of the neck with the shaft 
of the femur (1) ; the tension of the capsule (2) ; and the range of motion possible between the great trochan- 
ter and the superior rim of the acetabulum (3). (B) The usual displacement in fractures of the femoral 
neck. The outer fragment is pulled upward and backward by muscular pull (,1) and by gravity. (C) Full 
abduction relaxes muscular tension (,1). secures ligamentous tension of capsule (2), and forces the inner 
end of the outer fragment into place by the leverage action of the great trochanter against the superior 
rim of the acetabulum (3). (D) A form of impaction (1) which is broken up and reduction of fragments 
obtained by full abduction. (E) A form of incomplete fracture (1) which is corrected by full abduction 
of the limb. (Modified after R. Whitman.) 

the thigh in marked abduction. The same form of apparatus as in the 
method given above may be used except that the long external splint 
should not reach above the level of the trochanter. 

A third form), and this is of especial use in the young and the 
middle-aged who stand immobilization well, is the method of abduction 
to the full normal extent, devised and perfected by Whitman. He claims 
that the abduction method is based upon the anatomical construction of 
the joint, that its typical application implies the restoration of an approxi- 
mately normal contour of the bone, which he believes is possible in the 
great majority of cervical fractures of the femur. Whitman thinks it 
the only safe and practicable means of correcting deformity of the un- 
complicated or so-called non-impacted type. The patient, usually anaes- 
thetized, is lifted upon a pelvic support, preferably one furnished with 
a perineal bar for counter-pressure, and the extended limbs are supported 
by assistants. The assistant holding the uninjured limb abducts it to the 



528 TREATISE ON FEACTITRES 

normal limit, in order that it may serve as a guide and incidentally to 
fix the pelvis. The injured limb is first flexed and rotated sufficiently to 
disengage soft parts that may be interposed between fragments. It is 
then completely extended, and the assistant, by direct manual traction, 
overcomes the shortening, as demonstrated by measurement and by the 
relation of the trochanter to Nelaton's line, at the same time correcting 
the outward rotation. Still maintaining steady traction, he then abducts 
the limb to correspond with its fellow, the operator meanwhile supporting 
the joint and lifting the thigh upward. The pelvis should now be level 
and the extended limbs in exact correspondence in every particular. A 




Fig. 614. — The elevation, of the head of the bed (25 ) to provide a semi- 
reclining posture and thus to lessen the danger of thoracic congestion and to 
improve the nutrition of the injured part. (Whitman, in Annals of Surgery.) 

plaster-of-Paris spica is applied from the axilla to the toes. This should 
be carefully adjusted about the pelvis and trochanter. It should com- 
pletely cover the buttock and be heavily reinforced beneath that point 
and the thigh, that it may be unyielding to pressure and therefore effective 
as a posterior splint to hold the limb at its proper plane. This method 
aims at reducing the fragments and holding them in anatomical position 
until consolidation occurs (Figs. 613-616). 

Another form of treatment that has met with considerable success, 
especially by its originators, is the Ruth-Maxwell method. This con- 
sists in flexing the thigh at a right angle with the trunk to relax the psoas 
and iliacus muscles, and forcibly correcting the upward and backward 
'displacement while in this position. After such correction, continuous 
longitudinal and lateral traction is applied; the former by a Buck exten- 



FRACTURES OF THE FEMUR 



529 



sion apparatus, using from fifteen to twenty pounds of weight, and the 
latter by passing around the thigh on the anterior internal and posterior 
aspects padded binder's board, and over this a lateral traction apparatus 
with pulley and weight. This weight pulls outward and upward so as to 




Fig. 615. — The plaster spica holding the limb at the limit of normal abduction, illustrating 
the adjustment to the pelvis and to the hip. (Whitman.) 

raise the upper end of the shaft and trochanter to its normal position. 
Four to eight pounds of weight should be used for the lateral traction. 
Countertraction is obtained by raising the foot of the bed six to ten 
inches and the side of the bed corresponding to- the injured limb two to 




Fig. 616. — Application of plaster-of-Paris case. Whitman's method for fracture of the neck of the femur. 

four inches. This method has many advantages and is probably better 
than the simple Buck longitudinal traction method and perhaps may be 
as efficient and less troublesome than the Whitman abduction method. 
The heavy wire frame anterior splint of Nathan Smith or that of Hodgen, 
suspended from a gallows or other high fixed point, is valuable in these 
34 



530 TREATISE ON FRACTURES 

fractures. The original Thomas hip splint or its modified form used so 
much for fractures of the femur in the recent war may be found satisfac- 
tory if it is properly adjusted to the injured limb and fixed to the patient's 
trunk by swathe or straps. 

Cotton has recommended operative impaction in some fractures of the 
femoral neck which are without impaction from the injury. He strikes 
the trochanter with a mallet, thus causing locking of the fragments and 
encouraging union. This obviates to some extent the probability of 
disability that may arise if non-union should occur despite the usual 
treatment in the aged. 

In a few cases open operation and nailing of the fragments will be 
required. The cases calling for this procedure are those of non-union 
occurring in the young and middle-aged, robust individuals. In these 
cases either a nail or a fresh bone peg taken from the crest of the tibia 
may be used ( Albee's method) ; whichever method is used, immobilization 
should be obtained by the use of a gypsum spica. 

After-results. — In children and adults below the senile age good re- 
sults with only moderate shortening may usually be expected under skilful 
treatment. This is very apt to be true in fractures in the base of the 
neck of the bone. Fractures of the subcapital variety, that is, in the small 
part of the neck close to the head, especially in the aged, may show a 
tendency to non-union. Failure of union does not of itself mean entire 
loss of function. In many cases impaction has occurred at the time of 
fracture; and a large percentage of patients recover with fair anatomical 
and functional results. The report of the Committee on Treatment of 
Simple Fractures of the British Medical Association shows the following 
results obtained in fractures of the neck of the femur : 

Number of cases, 91 ; anatomical results, good, 18, moderate, 18, bad, 
39 ; functional results, good, 24, moderate, 28, and bad, 39. Percentage 
of good anatomical and good functional results, 16.4 ; percentage of moder- 
ate or bad anatomical with good functional results, 9.8 per cent. Average 
duration of incapacitation (non-operative) under fifteen years, 7 cases 
traced, average number of weeks of incapacitation, 26.5; over fifteen 
years, 65 cases traced, average number of weeks of incapacitation, 53.2. 
These results are probably much less satisfactory than those usually 
obtained in American surgical practice, when the surgeon himself takes 
care of the patients and inspects them frequently. 

Scudder believes that the fundamental principle in treating fractures, 
which is that reduction of the fragments should be effected before immo- 
bilizing apparatus is applied, has been too much ignored in fractures of 
the neck of the femur. He agrees with Whitman that this is in many 
cases unwise treatment; and that reduction of deformity, even if due 
to impaction, should, except in occasional cases, be attempted. Permit- 
ting the eversion or inversion and the shortening to go unrelieved is, 
in the opinion of these surgeons, improper treatment as a routine method. 



FBACTUKES OF THE FEMUR 



531 



In the very aged and in those in whom the abduction treatment after 
reduction of impaction or of " loose " deformity might increase the tend- 
ency to general depression of vitality, efforts to obtain anatomical resti- 
tution of contour may be omitted. Otherwise, Whitman's reduction by 
direct traction and abduction to an angle of about 45 ° from the longi- 
tudinal axis of the body is proper. This is to be accomplished under 
general anaesthesia, with the normal limb abducted to its full extent as a 
control. After impaction has been carefully unfolded or the " loose " 
fracture coapted, a long spica encasement of plaster-of-Paris bandage is 
applied to pelvis, hip, and thigh to immobilize the hip- joint and the 
fractured neck. The traction and abduction must be maintained until 



Fig. 617. 



Fig. 618. 




Fig. 617. — Normal limit of full abduction shown by dotted line. The outer surface of femoral neck strikes 

upper edge of acetabulum. The great trochanter comes against the soft tissues covering the ilium. 

Fig. 618. — Diagrammatic illustration showing impacted fracture of neck of femur while unreduced. 

It is also evident that abduction of the limb is forever limited, and adduction produced by union of an 

impacted fracture and the secondary contraction of the adductor muscles of the thigh. 

the gypsum sets. The thigh is usually fixed somewhat flexed on the pelvis 
as well as subjected to traction and abduction. A short spica to the knee 
made of the gypsum bandages may in some cases be sufficient ; in others it 
should be long enough to go to the ankle or to include even the foot. 
Sometimes both legs are encased. In fractures not impacted the shorten- 
ing should be overcome by traction before the abduction posture is given 
to the thigh for the application of the fixation dressing. This dressing- 
is worn in bed for about two months and crutches, without permitting 
weight-bearing upon the injured limb, are used for a month or two more. 
Separation of the Upper, or Capital, Femoral Epiphysis in Child- 
hood. — Separation of this epiphysis occurs in childhood, and was con- 



532 



TREATISE OX FRACTURES 



sidered by some authorities to be a rather rare injury. The epiphysis 
corresponds to the articular surface. Union with the neck occurs at the 
eighteenth to the twentieth year. During the past fifteen years, however, 
articles have been written by many surgeons, notably Hoffa, Hofmeister, 
and Whitman, which prove conclusively the comparative frequency of this 
injury. By some it is considered a true epiphyseal separation and by 
others a fracture of the neck of the femur close to the head. Often the 
lesion has been overlooked at the time of injury, and attention called to 
it only when there has developed a traumatic coxa vara as a result of the 
injury and the too early weight-bearing by walking. Sprengel, who first 
called the condition traumatic coxa vara, and Hoffa consider the lesion 
to consist of a complete or incomplete separation of the epiphysis of the 
head. Whitman maintains that the traumatic coxa vara usually is the 

result of a fracture of the neck 
of the femur. Radiographic 
examination shows generally 
either a true fracture of the 
neck near the head or a separa- 
tion of the epiphysis of the 
head with a portion of the dia- 
physis of the neck attached. 
The fracture or the epiphyseal 
separation is usually incomplete 
in character. Partial diastasis 
may be so slight as to be mis- 
taken for a mere sprain of the 
joints; and may be the local 
cause of an acute epiphysitis. 
Epiphyseal separation may be 
observed up to the sixteenth 
year, but the majority of cases 
occur from the eighth to the twelfth year. 

Etiology. — The lesion occurs after direct injury to the hip. 
Symptoms. — The patient, after being confined to bed, perhaps only 
for a few days, gets up and walks about with a little lameness but not 
enough to suggest to the parents grave injury to the hip. This is accounted 
for by the fact that the lesion is incomplete, or when complete, that firm 
impaction is present. Recovery takes place with a slight limp which fails 
to disappear, and later it is noticed that there is appreciable shortening 
of the femur, confined to the neck. As time goes on greater bending of 
the neck of the femur occurs, so that slight disability is replaced by marked 
disability. There is now added prominence of the great trochanter, slight 
eversion, marked limitations of abduction, and slight pain. 

When these cases are seen shortly after injury and the possibility 
of grave injury recognized, the symptoms present will depend upon 




Fig. 619. — Whitman's method of opening the impacted 
fracture by forcible abduction. 



FKACTUKES OF THE FEMUR 



533 



whether the fracture or separation is complete or incomplete. The differ- 
entiation between pure epiphyseal separation or fracture of the neck close 
to the head can only be made by radiogram. 

Diagnosis. — Fracture in or near the epiphyseal line is commonly the 
result of violence, such as a blow upon the hip, a fall upon the trochanter, 
a fall upon the feet or while jumping with marked outward rotation 
of the lower limb. The early symptoms are shortening, outward rotation 
of the thigh, prominence of the trochanter; if the fracture or separation 
is complete, there may be harsh or soft crepitus, depending upon the lesion 
present. In Scarpa's triangle there may be felt a swelling corresponding 
to the upper end of the displaced lower fragment. 




Fig. 620. — Whitman's method of reducing impaction of fracture of neck of right femur by traction and 
abduction. Tilting of pelvis prevented and normal degree of abduction established by assistant abducting 

the left limb. 



The condition should not be confused with tuberculosis of the hip- 
joint in childhood, which it closely simulates; and it should also be diag- 
nosed from the coxa vara due to softening of the neck of the femur, the 
result of deficiency in lime salts. 

In traumatic coxa vara the great trochanter is always above the Roser- 
Nelaton line; this occurs in tuberculosis of the hip-joint only when the 
disease is far advanced and diagnosis is unmistakable. A radiographic 
examination will clear up the diagnosis. 

Treatment. — Treatment depends entirely upon whether the condition 
is recognized at the time of injury or not until a resultant coxa vara 
is present. 

In recent fractures that are incomplete and in which deformity is 
present, the patient should be anaesthetized, reduction made, and immo- 
bilization in the abducted position obtained by the use of the gypsum spica 
bandage as advocated by Whitman. In complete fractures the treatment 



534 



TREATISE ON FRACTURES 




should be the same. After application of the plaster spica a radiogram 
will show whether reduction is satisfactory. In those cases in which 
reduction cannot be satisfactorily accomplished or maintained, open oper- 
ation, with bone pegging if necessary, is recommended. Immobilization 

should be maintained for eight 
weeks, after which a suitable hip- 
splint should be worn for six months 
to a year. 

In those old cases in which the 
condition is only recognized after 
coxa vara is pronounced and union 
is firm the line of treatment should 
be quite different. If the lesion is 
seen within a few months after in- 
jury and the surgeon believes that 
something may be gained by heavy 
traction, this may be used for a time 
in the hope of correcting the con- 
dition because union is not firm. 
When the diagnosis is made later 
and the 'condition of bent bone is 
marked and bony, osteotomy of the 



Fig. 621. — -Whitman's position of the femur when 

fixed in abduction by gypsum encasement applied 

as a spica bandage. The moulding over the ilium 

and condyle of femur gives firm support. 



neck or in the subtrochanteric region 



should be performed and immobiliza- 
tion obtained by a plaster spica for 

eight to ten weeks, after which time a hip-splint should be used for six 

to nine months. 

Fractures Through the Trochanters. — Under this term may be 

grouped the fractures involving the region of the trochanters (Figs. 

E 




Pig. 622. — Ossification of femur: (.4) at eighth fcetal month; (B) at birth; (C) during first year; (D) at 
eight years; (£) at about fifteen years, (a) centre for shaft; (b) lower epiphysis; (c) for head; (d) for great 
trochanter; (e) for lesser trochanter. 



FRACTURES OF THE FEMUR 

Fig. 623a. Fig. 6236. 



535 




Fig. 623c. 



Fig. 623d. 





Figs. 6230-623^. — Fractures of the femur through the trochanters. 

623^.-6230?). As a rule the fracture line is irregular and runs through 
the great trochanter, splitting it through the intertrochanteric line to a 
point above the lesser trochanter. In a few instances the latter will be 



536 



TREATISE ON FRACTURES 



found split in two or separately detached from the shaft, or the fracture 
line may be spiral in character so that the upper fragment extends down- 
ward and consists of a pointed piece of bone, a part of the shaft. As 
a rule moderate comminution is present. These fractures should be 
separated from those occurring at the base of the neck and from those 
of the subtrochanteric region. In subtrochanteric breaks rarely does the 
small trochanter form a part of the upper fragment. The important clini- 
cal difference of this fracture below both trochanters is that the action 
of the psoas and iliacus muscles tends to tilt the upper fragment upward 



Fig. 624. 



Fig. 625. 




Figs. 624 and 625. — Fractures of the great trochanter of the femur. 

and rotate it outward. Formerly this form of fracture was considered 
rather rare, but from a study of radiograms its comparative frequency 
is manifest. 

Etiology. — Fracture through the trochanters is observed frequently 
in middle adult and early late life, the result of either a direct fall upon 
the trochanteric region or more commonly of a fall in which the extremity 
is in marked adduction. The lesion sometimes partakes of the nature of 
a torsion fracture. In torsion fractures the line of split is through the 
great trochanter and intertrochanteric line ; and the lesser trochanter either 
is split into two fragments or it is separately detached by the action of the 
psoas and iliacus muscles. 

Symptoms. — The symptoms of fractures through the trochanters are 



FRACTURES OF THE FEMUR 537 

prominence of the great trochanter, marked thickening in the region of 
the trochanters, complete disability, shortening of the limb, and eversion 
due to muscular relaxation, the weight of the limb and lack of control, 
with slight or absent impaction of fragments; rotation of the limb shows 
the radius of motion to have its centre near the shaft's centre and not 
in the acetabulum or the shaft of the femur, pain, tenderness on pressure, 
particularly over the region of the great trochanter and upper part of 
the shaft. Crepitus may be felt, if there is absence of impaction, upon 
rotating the shaft of the femur combined with traction. 

Prognosis. — Fractures through the trochanters are extra-articular, 
and are usually followed by firm union, with considerable thickening 
from excessive callus in the trochanteric region, and a moderate degree 
of shortening. Some limitation of the normal range of motion is gener- 
ally permanent, and the patient recovers with a slight limp and has at 
certain times considerable permanent pain over the seat of fracture and 
down the outside of the thigh. Under careful treatment permanent ever- 
sion should result. 

Treatment. — As union of fragments occurs in this region, the ques- 
tion of impaction or non-impaction is not as important as in fracture of 
the neck of the femur. The majority of fractures through the trochanters 
will be found to be but slightly impacted or quite unimpacted. Unless 
there is some marked contra-indication, such as the patient's age, all of 
them should be treated as unimpacted fractures. It is probable that 
anaesthesia generally should be used for reduction. This is to be accom- 
plished by longitudinal traction in the abducted position and with counter- 
traction by a strap around the perineum. All eversion and shortening 
should be corrected and parts placed permanently in the abducted position, 
after the Whitman method, in a gypsum spica. If for any reason this is 
not considered feasible, a Buck traction apparatus with from 15 to 25 
pounds of weight should be applied with the limb in the abducted position, 
and an external axillo-tarsal and perhaps a posterior splint. The foot 
of the bed should be raised, and on the affected side the bed should be 
higher than on the other side of the patient. A heavy moulded gypsum 
splint from axilla to ankle is better than the wooden splints. After four 
to six weeks a plaster spica may be applied and a few weeks later the 
use of crutches may be permitted if the well foot wears a high sole shoe. 
The weight-bearing of walking should not be begun for at least three 
or four months. 

Fracture of the Great Trochanter, or Separation of the Apophysis. — • 
Isolated fracture of the great trochanter (Figs. 624 and 625) is a very rare 
injury. In conjunction with fracture at the base of the neck or through 
the intertrochanteric line it is occasionally seen. The apophysis unites 
with the diaphysis of the bone, at about the eighteenth year. 

Etiology. — Fracture of the great trochanter, or separation of this 
apophysis, is the result of direct violence or of muscular action. When 



538 



TEEATISE ON FRACTURES 



the result of direct violence, there may be comminution. When the result 
of muscular action, it partakes of the nature of a tearing off of the cortex 
of the trochanter, while the same form of injury before the time of union 
of the apophysis with the diaphysis will result in a complete separation of 
the apophysis. The amount of displacement is dependent upon the perios- 
teal covering of the trochanter. The fragment is often held in quite good 
position by untorn portions of the periosteum and deep fascia. 

Symptoms. — At first there may be only the symptoms usually associ- 
ated with contusion. There is localized pain and tenderness on pressure, 
and on palpation it may be possible to distinguish the movable fragment. 

Displacement of the fragment upward 
and backward by the action of the 
gluteus medius and minimus muscles 
(Fig. 626) is present, when the muscu- 
lar attachments are torn from the dia- 
physis of the bone; this displacement* of 
the upper fragment may be as much as 
several inches. In the absence of local- 
ized swelling, flattening over the tro- 
chanter will be noted. Crepitus may at 
times be obtained by flexion, abduction, 
and outward rotation of the thigh and 
by pressing the fragments together. Pri- 
marily, palpation of the fragment and 
crepitus are not obtainable on account of 
the localized pain and muscular spasm 
present. The thigh is generally held 
flexed and rotated inward, active motion 
is painful, abduction is limited or impos- 
sible, and shortening of the limb seen in 
cervical or shaft fractures is absent. 
Prognosis. — Union is generally 
in character, unless operative 
treatment by nailing or suture is 
adopted. Future functional result may 
be quite good even with fibrous union. 

Treatment. — The non-operative treatment of fixation is a plaster spica 
in the abducted flexed position with the thigh rotated outward. If 
radiographic examination shows approximation of fragments is not good 
by this method, open operation with direct fixation of the fragment with 
a nail suture should give good results. 

Fracture of the Lesser Trochanter. — Isolated fractures of the small 
trochanter are extremely rare. Fracture of this process is more likely 
to be seen in conjunction with fractures through the trochanteric region. 
Isolated cases have been reported by several authors, and in them the 




Fig. 626. — Drawing to show the type of dis 
placement which occurs in fracture of the fibrOUS 
great trochanter. The trochanter is pulled 
upward and backward by the action of the 
gluteus medius and minimus muscles. 



FBACTURES OF THE FEMUR 



539 



condition has been recognized either by radiograms or has been confirmed 
by autopsy. 

Etiology. — Of the reported cases the majority were observed in boys 
of seventeen years or younger, and were the result of muscular action in 
running or in avoiding a fall. Three cases were in men beyond middle 
life, in which the injury was due to muscular pull in falling. In one case 
the patient was run over by an omnibus. The lesion consisted of a tearing 
off of the lesser trochanter, and in two of the cases a portion of the shaft 
was attached to the fragment. The injury is due to the pull of the psoas 
and iliacus muscles. 

Symptoms. — The symptoms of fracture of the small trochanter are 
local pain and tenderness on pressure, which are increased by attempts 



Fig. 627a. 



Fig. 627b. 




Figs. 627a and 6276. — Subtrochanteric fractures of the femur. 

at active flexion or passive extension of the hip- joint. In some of the 
reported cases the patients were able to walk; various degrees of eversion 
were present. Ecchymosis on the inside of the thigh appearing after 
twenty- four hours, together with swelling, is usually present. A posi- 
tive diagnosis of the condition can only be made by radiogram. 

Treatment. — This should consist in immobilization in a plaster-of- 
Paris spica with flexion and inversion at the hip-joint. Union should 
occur in from six to eight weeks and may be fibrous in character. 

Fractures of the Subtrochanteric Region. — Fracture of the femur in 
the subtrochanter region (Figs. 627a and 627b) are relatively frequent. 
Three varieties of fracture are seen in this region : the transverse, the 
oblique, and the spiral. 



540 



TEEATISE ON FRACTURES 



Etiology. — Fractures below the trochanter are the result of either 
direct violence or indirect force. When resulting from direct violence 
the fracture line is apt to be transverse, while those occurring from in- 
direct violence are either oblique or spiral in character. 

Symptoms. — Fractures of this region are unimpacted. The symptoms 
are absolute disability, shortening, which is often marked, due to angu- 
larity of fragments and overriding. Shortening is not marked in the 
transverse variety of fracture. There is marked outward rotation of 
the thigh and leg, due to gravity and lack of 
bony continuity, and free mobility of the lower 
fragment. Rotation of the shaft does not show 





Fig. 628a. — Dissection showing displacement in fracture of femur FlG. 6286. — Shows forward and 

near middle of shaft. The psoas and iliacus, inserted by common outward deformity near middle of 

tendon into small trochanter, flex and rotate outward the upper thigh and shortening of limb. (See 
fragment. (See Fig. 6286.) (Helferich.) Fig. 628a.) (Helferich.) 

corresponding rotation of the trochanter. Crepitus may be elicited when 
the line of fracture is transverse, as in this instance displacement of frag- 
ments is not great; but crepitus is difficult to obtain in the oblique and 
spiral forms of fracture on account of the overriding displacement of 
fragments and the interposition of soft parts. Deformity is generally 
marked, and consists of flexion with outward rotation of the upper frag- 
ment, due to the pull of the psoas and iliacus muscles upon the upper 
fragment, and abduction from action of the gluteus medius and minimus 
muscles upon the same fragment. The lower fragment is drawn upward, 



FEACTUEES OF THE FEMUE 



541 



causing marked shortening of the limb. This shortening is due to the 
pull of the rectus in front and of the biceps, semi-membranosus and semi- 
tendinosus behind. In addition to these symptoms there is pain, localized 
tenderness, swelling, and ecchymosis ; and sometimes the sharp point of 
the lower end of the upper fragment may be felt on the anterior surface 
of the thigh. Occasionally puncture of the skin is threatened or is actually 
produced by this sharp fragment. The exact variety of fracture and 
position of fragments may be determinable only by radiogram. Many 
fractures are so situated as to partake of the nature of fractures of the 
shaft in the upper third. 

Prognosis. — Union takes place in the transverse fractures when there 
is little or no displacement of fragments with little or no deformity. In a 
considerable proportion of instances, however, the difficulty of maintain- 





FiG. 629. — Diagrammatic illustration of 

displacement in substrochanteric fracture 

of shaft. 



Fig. 630. — X-ray, fracture below lesser tro- 
chanter; flexion and great abduction by muscle 
action. 



ing reduction and accurate approximation of fragments results in some 
overriding of fragments, with consequent shortening and anterior and 
external angular deformity. These defects may be largely due to ineffi- 
cient or careless supervision of the treatment. 

Treatment. — The problem of treatment of fractures in this region is 
often very trying. Reduction as a rule can be readily accomplished, but 
the difficulty of maintaining reduction taxes the ingenuity of the surgeon 
and calls for careful observation of the fracture at all times. In cases 
in which there is little if any flexion, external rotation, or abduction of 
the upper fragment, apposition of fragments may be maintained by the 
use of Buck's traction apparatus, using fifteen to twenty pounds of weight 
with the hip moderately Hexed and the knee nearly extended; with a 



542 



TREATISE OX FRACTURES 



padded posterior splint from the upper end of the thigh to a point above 
the heel, and a long external splint from the axilla to below the foot ; and 
elevation of the foot of the bed for a distance of ten inches. If there is 
a tendency toward abduction of the lower end of 
the upper fragment, this displacement may be over- 
come by the use of a pad between the external splint 
and the lower end of the upper fragment, by traction 
in the abducted position, or by the use of a plaster 
spica with traction, applied with the limb in a posi- 
tion of abduction and slight external rotation. The 
long splint with a pad is seldom if ever wise, unless 
the fragments can be successfully locked at the time 
of reduction. Anaesthesia is desirable in most frac- 
tures of the shaft, both for a correct understanding 
of the injury and to permit proper reduction. 

In the presence of more marked flexion and 
eversion deformity of the lower end of the upper 
fragment, several procedures may be adopted. The 
lower fragment must be brought in line with the 
upper fragment. This may be accomplished in chil- 
dren by vertical extension; adults may not take 
kindly to this form of extension. In adults, ana- 
tomical apposition may be maintained by the use of 
a plaster spica from the lower chest level to the 




Fig. 631. — Long splint for 
fracture of femur below 
trochanters, with pad to 
prevent abduction of 
upper fragment. 




Fig. 632.— Modified Zuppinger's apparatus for treatment of fractures in the subtrochanteric region. 

Traction is obtained through an adhesive plaster dressing applied with the hip- and knee-joints flexed. 

Coaptation splints preserve to a great extent lateral alignment of the fragments. Sufficient weight 

should be used to correct overriding of fragments. 



03*4 



3 Jh 



3 3- 

ess 



p p 






3 n> r* 
H 3 2". 



p *' 









g p. 



2& 

2.5 




FKACTITKES OF THE FEMTJE 543 

knee, applied with the thigh in a position of flexion and eversion and 
the use of traction from the thigh. The coaptation of fragments may 
be maintained, and usually more satisfactorily, by the use of the 
Xathan R. Smith anterior suspension splint or Hodgen suspension 
splint; or perhaps by employing the double-inclined plane, with trac- 
tion in the line of the displaced upper fragment. The value of these 
methods is in the fact that the lower fragment is brought into align- 
ment with the flexed, everted and abducted upper fragment. Sus- 
pension is usually better, when combined with traction, than with the 
double-inclined plane methods. Suspension and traction- may be 
obtained by using the Thomas traction splint, as employed in the United 
States Army service, and suspended from the Balkan frame. Counter- 
traction is made by pressure of the ring at the upper end of the splint 
against the innominate bone. 

In some fractures at this site, longitudinal traction, posterior 
splint and a long external splint, combined with a bag of shot or 
sand over the lower end of the upper fragment, may give satisfactory 
apposition. This method requires considerable attention and is not 
strongly advocated. If satisfactory position cannot be obtained by one 
of these methods, operation and direct fixation of the fragments by a steel 
plate or suture is advocated. These fractures are especially adapted to 
the plate fixation method because of the difficulty of maintaining coapta- 
tion by external apparatus when displacement is marked. The Hawley 
table is valuable for securing mechanical aid in reducing fractures and 
maintaining coaptation during the application of gypsum encasements. It 
is also of great service during blood-shedding operations for direct fixation 
with suturing of fragments or applying plates, pegs or screws. 

Whatever method of treatment is used, it should be continued, if satis- 
factory, until firm union has taken place; weight-bearing should not be 
attempted for at least twenty to thirty weeks afer the time of injury. 



CHAPTER XXII 

FRACTURES OF THE SHAFT OF THE FEMUR 

Fractures of the shaft of the femur include those occurring below 
the subtrochanteric region and above the supracondylar site. They are 
most commonly met with during active adult life and in the male sex, 
and usually affect the middle, occasionally the upper, and rarely the lower 
third of the bone. Of 55 fractures of the shaft of the femur observed 
by Plagemann, the upper third was involved 9 times, the middle third 40 
times, and the lower third 6 times. The fracture line was irregularly 
transverse 28 times, spiral 13 times, oblique 8 times, and oblique with a 
third fragment 6 times. In this series, therefore, one-fifth of all fractures 
of the shaft are spiral in character. 

Etiology. — Fractures of the shaft of the femur are, as are other 
fractures in the shafts of long bones, the result of direct or indirect 
violence or of muscular action. Fractures from direct violence are most 
frequently found in the lower third of the bone, and are due to crushing 
injuries, such as from falling walls or weights and being run over by 
vehicles. Fractures by direct violence occur most frequently in the 
middle and occasionally in the upper thirds of the bone, as in a fall upon 
the feet. Muscular action is found as a cause in fractures in the upper 
and occasionally in the middle thirds of the femur, which result from a 
sudden twist of the body and upper part of the thigh with the foot in 
a fixed position. Direct agencies, such as exist in warfare, cause open 
fractures, many of which become infected. 

Varieties. — The line of break follows certain definite lines, depending 
upon the position of the fracture and the nature of the violence (Figs. 
633-640). Fractures by direct violence are usually transverse; at times 
there is a three-cornered piece of bone broken off at the point distal to 
the direction of force. Fractures by indirect violence are generally 
oblique, while fractures by muscular action are spiral in character; here 
the fragments are often very sharp and oblique, and at times there is 
a rhomboidal portion of bone detached at a point of fracture. Oblique 
and spiral fractures show a tendency to be open, due to the piercing 
of the soft parts and skin by a sharp fragment ; fractures by direct violence 
are more apt to be comminuted as well as open, and not infrequently are 
attended with considerable destruction of overlying soft parts. Longi- 
tudinal splits occasionally take place. Incomplete fractures in the fem- 
oral shaft are extremely rare. 

Symptoms. — The symptoms of complete fracture of the shaft of the 
femur are loss of voluntary motion, or if any motion is present attempts 
544 



FRACTURES OF THE SHAFT OF THE FEMUR 545 

to lift the leg from the bed show angular deformity at the seat of fracture. 
There are present deformity, abnormal mobility (Fig. 641) and crepitus 
at the site of fracture, eversion of the knee, leg and foot, and shortening 
of the limb. The shortening is due to the obliquity of the fracture line 
permitting overriding of the fragments from the muscular pull. There 
is swelling from infiltration of soft parts beneath the deep fascia about the 
seat of fracture. Shortening may be overcome by strong, steady traction 
and countertraction, and its presence may be estimated by measurement 
of both extremities from the anterior superior spine of the ilium to the 
internal malleolus or to the tibial tubercle, or from the umbilicus or en'si- 



\ 





Fig. 633. — Type of fracture of the upper third of the shaft of the femur. 

form cartilage to the malleoli. Shortening varies from one to five or six 
inches. In making these measurements the patient should be placed upon 
a flat, firm mattress and the extremities should be at right angles to a line 
drawn through the two anterior superior spines of the ilium. The asym- 
metry in length of normal bones must not be forgotten in estimating short- 
ening in fractures. In transverse fractures there may be little or no 
shortening because of the absence of marked displacement of fragments 
or of entanglement or impaction of fragments. Displacement of frag- 
ments and angular deformity are, however, the rule in complete, unim- 
pacted fractures. Factors acting in the production of displacement are 
the direction of the fracturing force, the curve of the bone, and the trac- 
35 



546 



TEEATISE OX FRACTURES 




FRACTURES OF THE SHAFT OF THE FEMUR 

Fig. 635a- Fig- 6356. 



547 





Fig. 636a. 



Fig. 6366. 





/ 



Figs. 635a and 6356 and 636a and 6366. — Types of fracture of the lower third of the shaft 

of the femur. 

tion of attached muscles. Rotation of the lower fragment externally is 
the rule in all fractures of the shaft and is due to the weight of the 
limb (Figs, 638-646). 

Typical Displacement in the Different Regions. — In fractures of 



548 



TREATISE ON FRACTURES 






FRACTURES OF THE SHAFT OF THE FEMUR 549 

the upper third of the shaft (Fig. 647) the lower end of the upper frag- 
ment tends to be displaced forward and rotated outward. This deformity 
is due to the action of the psoas and iliacus, and the gluteus medius and 
minimus muscles, while the upper end of the lower fragment is drawn 
upward, inward and posteriorly by the action of the adductor of the thigh 
and flexor muscles of the knee-joint. Angular displacement is thereby 
produced. Displacement, however, may be absent in transverse fractures 
and in those close to the trochanters. In fractures of the middle third 
(Figs. 648 and 649) close to the upper third, the same type of displace- 
ment of fragments may occur as in fractures of the upper third. When, 
however, the line of fracture is below the attachment of the short and long 




Fig. 638. — Type of fracture of shaft of femur occurring in- childhood. 

adductor muscles, the lower end of the upper fragment is drawn inward 
and forward and the lower fragment is displaced upward, outward, and 
backward. In fractures of the lower third the lower end of the upper 
fragment is drawn inward and forward by the adductors of thigh and 
extensor muscles of the knees, and the lower fragment upward and back- 
ward by the flexor muscles of the knee. At times the upper end of the 
lower fragment is also rotated backward by the action of the gastroc- 
nemius muscle. 

Other symptoms present are pain, localized tenderness on pressure, 
swelling, ecchymosis, and muscular spasm. Early effusion into the knee- 
joint is often present in fractures of the lower third of the shaft. 

Complications. — In fractures of the upper and middle thirds of the 
shaft complications are rare. In fractures of the lower third they are 
occasionally present. Puncture of the muscles and skin by a sharp- 
pointed fragment may cause the injury to be an open one. The pre- 



550 



TREATISE ON FRACTURES 



Tensor fasciae femoris, 

Gluteus medius 

Gluteus minimus 



Rectus femoris 



Crureus 



Vastus internus 




Iliopsoas 

Pectineus 
Adductor brevis 

Adductor longus 



Gracilis 



Adductor magnus 



Fig. 639a. — Fracture of the femur at the juncture of the upper and middle thirds. Upper fragment drawn 

forward and outward. 

patellar bursa may at times be penetrated. Vessel injury, such as rupture 
or compression of the femoral artery or vein with resulting hemorrhage, 
aneurism, or gangrene, may happen. Nerve injury is extremely rare 
from shaft fractures, but occurs to the popliteal or peroneal nerves in 
condylar or supracondylar breaks. 



FRACTURES OF THE SHAFT OF THE FEMUR 



551 



Prognosis. — The prognosis in fractures of the shaft of the femur is, 
as a rule, favorable. Union occurs ordinarily in six to ten weeks, after 
which time patients may be allowed up on crutches, provided the line of 
fracture is supported by a, plaster spica dressing from waist to below 
knee, or by a suitable brace. The weight-bearing in walking should be 
prohibited for four or five months from the time of injury. The arching 
forward of the shaft of the normal femur should not be forgotten in re- 
constructing the bone after fracture. Little permanent shortening should 




Plantaris 

Two heads 
of the 
gastrocnemius 



Fig. 6396. — Supracondylar fracture of the femur. The lower 

fragment is seen to be drawn back into the popliteal space by 

the gastrocnemius and plantaris. The vessels are stretched 

over the sharp edge of the lower fragment. 

follow well-treated fractures of the femur if good anatomical apposition 
of fragments is obtained. This, as a rule, is not obtained as often as it 
should be, except in the most favorable cases. This defect in result is prob- 
ably due to the injury not being examined and the fracture reduced under 
general anaesthesia. A fractured femur is a major surgical lesion and 
should be treated by a trained surgeon and not left to a junior medical 
officer of a hospital, or to an inexperienced medical attendant. Abso- 
lute reconstruction of the length of the bone is not extremely important. 



552 



TREATISE ON FRACTURES 




Shortening is the rule in oblique, spiral, comminuted fractures and in 
fractures uniting in a position of overriding or angulation. This may 
vary from a fraction of an inch to several inches. If, however, union is 
obtained with the fragments in good alignment, without rotary dis- 
placement, a shortening of even three-quarters to an inch will cause little 
limp in gait, and can be considered as a good functional result by non- 
operative means. A slight addition to the heel of the shoe or a pad of 
leather within the shoe under the patient's heel will correct the limp and 
prevent lateral spinal deviation. 

When these fractures are subjected to operative fixation, there should 

be no shortening angulation or 
rotary displacement, unless the frac- 
ture is comminuted or local necrosis 
of bone follows operation. Union 
as a rule is delayed by operative 
fixation. In stout people and in the 
aged the possibility of hypostatic 
pneumonia, bed-sores, and fat em- 
bolus should always be considered. 

Effusion into the knee-joint is 
usual in fractures of the lower third 
and is the result of the primary vio- 
lence, the penetration of the joint 
cavity by sharp fragments of bone, 
or the extravasation of blood at the 
time of fracture. It may occur 
shortly after the time of injury and 
may be serous or sanguineous in 
character. Another form of effusion 
is that seen when the patient begins 
to use the knee-joint after convales- 
cence. The effusion is the result of 
strain of use upon atrophied and 

Fig. 6 4 o.-Comminuted fracture of shaft of femur. quiescent Structures ^ about the joint. 

GE'dema of the leg is due to change 
of position, muscular activity, or to partial venous or lymphatic obstruc- 
tion at the seat of fracture. 

Muscular atrophy, the result of disuse, may persist for some time, 
while rigidity of the knee may be persistent, particularly in the aged 
and rheumatic. These sequels often may be averted if early- passive and 
active movements and very careful massage are employed daily or two 
or three times a week from the beginning of treatment, following the 
advice of Lucas-Championniere. Hence the defect of prolonged abso- 
lute immobilization. 




FRACTURES OF THE SHAFT OF THE FEMUR 



553 




I 



Fig. 641. — Method of determining abnormal mobility and crepitus in fracture of the shaft of the femur. 
Fig. 642a. Fig. 642ft. Fig. 643a. Fig. 6436. 




Fig. 642a. — Femur; fracture through trochanters; union has taken place with shortening, angulation. 

and outward rotation of the lower fragment. (Wistar Institute of Anatomy.) 
Fig. 642b.— Femur, right; fracture of the upper shaft. Union with anterior angular deformity. The 
fracture occurred at the junction of the middle and upper thirds, and was probably nearly transverse. 
The psoas magnus and internal iliac muscles have elevated the end of the upper fragment 55 degrees 
so that the bones have united with great anterior deformity. The lower fragment has passed upward 
and backward. There is no outward quotation of the lower fragment. (Mutter Museum, No. I397-035-) 
Fig. 643a. — Femur, right; fracture of the neck, trochanter major and shaft; recent. The injury was 
a severe one in which, while the trochanter was fractured by direct violence, the shaft was probably 
broken by twist, leverage being obtained at the knee. The upper fragment_ consists of the head, neck, 
trochanters and a portion of the outer shaft, terminating in a point. Passing from this point 13 cm. 
below the great trochanter we trace a line passing spirally upward and backward. Looking on the 
external surface of the great trochanter, a Y-shaped fracture is seen. (Mutter Museum, No. 1307.031.) 
Fig. 6436. — Femur, right; transverse fracture of middle shaft. Recent union. The fracture occurred 
just above the middle. The lower fragment passed 'upward to the inner side and slightly backward. 
The shortening amounts to 5 cm. The lower fragment has rotated outward 20 degrees. (Mutter 

Museum, No. I397-055-) 



554 TREATISE ON FRACTURES 

Pseudarthrosis is occasionally seen as the result of overriding of 
fragments, failure of reduction, interposition of soft parts, faulty im- 
mobilization of fragments, operative necrosis, and general systemic 
diseases. The most frequent cause of poor functional results are failure 
of reduction, allowing shortening, angulation, rotary displacement, faulty 
immobilization, exuberant callus, muscular atrophy, stiffness of knee-joint 

Fig. 644. Fig. 645. Fig. 646. 




Fig. 644.— Femur, left; fracture of the middle shaft. There is great shortening 
and anterior angular deformity. Sharp prominence of the upper fragment. 

(Mutter Museum, Xo. 1397.058.) 
Fig. 645. — Femur, left; fracture of the lower shaft; union with deformity. The 
fracture occurred at the junction of the middle and lower third and was probably 
nearly transverse. The lower fragment points inward 10 degrees but has not 
rotated. It has passed upward and backward and has united firmly. The upper 
fragment presents a prominence anteriorly while the lower fragment projects on 
the outer side. The inner side of the line of junction is grooved. (Mutter 

Museum, Xo. 1397.071.) 

Fig. 646. — Femur; fracture of the shaft, junction of the middle and lower thirds. 

Union with marked deformity, consisting of overriding and inward rotation of 

the lower fragment, and the formation of exuberant callus as a spur from the 

lower end of the upper fragment. (Wistar Institute of Anatomy.) 

and pseudarthrosis. A fractured femur usually requires skilled treat- 
ment, if deformity and ambulatory disability are to be averted. 

Treatment. — In the treatment of fractures of the shaft of the femur 
the method of procedure will depend in a great measure upon the site 
and the line of fracture, the amount and direction of displacement of 



FRACTURES OF THE SHAFT OF THE FEMUR 



555 



fragments, and the age of the patient. Operation and direct fixation of 
fragments usually give good results in fractures of the shaft of the femur, 
provided the operator be experienced and have a perfect aseptic technic. 
They overcome many of the difficulties attendant upon non-operative 
treatment in difficult cases. This is particularly the case in the fractures 
of the upper and lower thirds 

of the bone with marked dis- ' /. / 

placement of fragments. In 
healthy adults, in whom opera- 
tion is not contra-indicated, this 
form of treatment would be the 
choice for fractures in which 
there is grave difficulty in re- 
duction or in maintaining 
reduction by non-operative 
means. Unfortunately the 
depth of the femur and the 
strong muscles surrounding it 
make the operation a difficult 
one for the occasional operator, 
and greatly increase the risk of 
septic complications. 

In those cases in which 
good results reasonably may be 
expected by non-operative 
measures, the exact method of 
retaining the apposition of 
fragments will be selected ac- 
cording to the site of the frac- 
ture. In the majority of cases 
the reduction of fragments and 
the application of immobilizing 
apparatus should be performed 
under general anaesthesia. The 
omission of the anaesthesia has 
been the explanation of many 
bad anatomical results and has 
caused the operative fixation to 
obtain many advocates. The 
patient's bed should have a level, firm mattress, which should be addi- 
tionally supported by several flat boards placed under it running across 
from the sides of the bed. A wire spring mattress, indeed any form of 
spring mattress, is an almost inexcusable error. 

In many fractures of the shaft reduction may be accomplished readily 
by immediate traction and countertraction, especially if general anaes- 




V 






Fig. 647. — Drawing to show type of displacement which 
may occur in fractures of the upper third of the shaft of 
the femur. The upper fragment is pulled upward, forward 
and outward by the action of the iliopsoas and gluteus 
medius and minimus, and the lower fragment is pulled 
upward and inward by the quadratus femoris, the biceps 
and adductor muscles. 



556 



TREATISE ON FRACTURES 



thesia be used. This is particularly so in transverse and oblique fractures. 
The pelvis and upper part of the thigh should be held firmly by one assist- 
ant, while another makes prolonged and steady traction by grasping the 
foot and leg with both hands. The surgeon meanwhile endeavors to 
obtain complete reduction by manipulation. In fractures of the upper 
third, or at the junction of the upper and middle thirds, it will often be 



Fig. 648. 



Fig. 649. 




Fig. 648. — Fracture of the middle of the shaft of the femur in childhood. Note overriding and angu- 
lation of fragments, and outward rotation of the lower fragment. 
Fig. 649. — Drawing to show the action of the thigh muscles in causing displacement of fragments. 
(Made after rontgenogram, Fig. 648.) 

necessary to elevate the leg and knee so as to bring the lower fragment 
in a line with the upper, which may be flexed and abducted by the iliopsoas 
and the gluteus medius and minimus muscles. In fracture of the lower 
third, flexion at the hip and knee with steady traction on the flexed leg 
will generally result in reduction. When there is impalement of the 
muscles upon the sharp end of a fragment they may be freed by rotation 
of the fragment. If not thus released, an incision may be required to 



FEACTUEES OF THE SHAFT OF THE FEMUR 



557 



accomplish this object. After the fracture has been reduced and the 
ends of the fragments engaged, so as to make the coaptation perfect or 
nearly so, an immobilizing dressing is to be applied while the patient is 
relaxed and free from spasm and pain by the amesthetic. 

Various forms of immobilization apparatus may be used to maintain 
proper reduction of fragments. The one that has the greatest field of 
usefulness is the modified Buck traction apparatus. It is very satisfactory 
in fractures of the middle third, of the upper third, when there is little 
tendency toward flexion and outward displacement of the lower end 
of the upper fragment, and in fractures of the lower third where the 
upper end of the lower fragment is not drawn backward. It is applied 
in the following manner : The leg and thigh are cleansed with soap and 





Fig. 650. — Method of applying Buck's traction apparatus. Adhesive plaster spreader to keep pressure 

from the malleoli, a padded posterior splint to keep the heel from the bed. This dressing should be 

supplemented by a Liston or T-splint or by sand-bags to steady the extremity. 

water, shaved, and bathed w r ith alcohol and ether. After reduction of 
the fracture, two strips of rubber adhesive plaster three inches in width 
and long enough to extend from a point four inches above the seat of 
fracture to six inches below the foot are smoothly applied along the 
middle of the internal and external surfaces of the leg and thigh from 
above the seat of fracture. The malleoli are protected by several layers 
of a flannel bandage, and three circular strips of plaster one and one-half 
inches wide are applied circularly almost completely around the limb ; one 
is placed two inches above the malleoli, one below the knee, and the third 
just below the seat of fracture. Instead of the three circular strips, rein- 
forcement of the lateral strips may be secured by strips of plaster two 
inches in width applied diagonally from two inches above the malleoli 
to the seat of fracture. 



558 



TREATISE ON FRACTURES 



Two ends of the longitudinal strips are secured to a spreader or stir- 
rup, made of wood three inches wide, four and a half to five inches long, 
and perforated at its centre by a hole for the traction rope (Fig. 650). 

by a bandage from just above the 



The adhesive dressing is covered 




Fig. 651. — Second stage of the modified Buck's traction apparatus. A cotton roller bandage has been 
applied from the malleoli to the lower third; the thigh is surrounded by several layers of sheet- wadding 
and coaptation splints have been applied to the thigh. Sometimes the coaptation splints may be omitted 
or a gypsum-gauze contour trough substituted. If the fracture is reduced well, before applying the 
dressing, this is especially the case. 




Pig. 652. — The dressing is completed by an internal splint, a Liston or T external splint, a body swathe 
to hold the upper end of the splint against the pelvis, and bed-blocks to elevate the foot of the bed. 

malleoli to the level of the upper end of the lower fragment. The ends of 
the traction strips of plaster are then turned down over the inner layers 
of bandage, and the bandage carried upward almost to the hip. A 
posterior or ham splint of wood or metal, well padded, is placed poste- 



FEACTUEES OF THE SHAFT OF THE FEMUE 



559 




riorly, extending from the upper level of the thigh to two inches above the 
calcaneum, and is secured with three strips of adhesive plaster (Fig. 
651). This splint is only occasionally needed if the bed is level and firm 
and a soft pillow is placed under the popliteal space. The knee should be 
almost, but not fully, extended. Coaptation splints to surround the thigh 
on the internal anterior and external surfaces' are 
applied and held in place by three strips of adhesive 
plaster or webbing straps. An internal splint is applied, 
from one inch below the perineum to one inch above 
the internal malleolus, and a long splint from the mid- 
chest region to a point two inches below the sole of the 
foot. These two splints are secured to the thigh and 
leg by webbing straps, and the external splint is held 
to the chest wall by a wide swathe, and a similar one 
is placed about the splint and pelvis (Fig. 652). In 
applying this apparatus care should be taken to see that 
the inner surface of the first metatarsal, the middle of 
the patella, and the anterior superior spine of the ilium 
are in a straight line and the foot is not too much 
everted. After its application the patient may be placed 
on a Bradford frame, the foot of the bed elevated eight 
inches or more, a pulley attached to the foot of the bed, 
over which is carried the rope, connected with the 
spreader. To the end of the rope from fifteen to thirty- 
five pounds weight should be added for keeping up 
traction on the thigh muscles. Countertraction is 
obtained by the weight of the patient; and if this is not 
sufficient, perineal straps connected with the head of 

the bed may be used. A bed- 
cradle should be placed over the 
patient's legs to keep the weight 
of the bedclothing off the feet. 

This form of apparatus re- 
quires constant supervision. Care 
should be taken to see that traction 
is constant, that overriding of 
fragments has not recurred, that 
outward or posterior angulation 
at the seat of fracture is prevented, 
and that inward or outward rotation of the leg and lower fragment is 
not present. This supervision is more likely to be maintained and devia- 
tions at the point of break discerned if the internal lateral splint, the 
Bradford frame and the Liston external splint are omitted and boxes of 
bricks or good sand-bag support used instead. This change is permissible, 
in the opinion of one of the authors, in many instances. The omission 



653. — Long out- 
side T-splint; extends 
from the axilla to be- 
low the foot. Applied 
with a swathe to the 
chest. The leg, with 
or without a back 
splint, is strapped to 
the splint to steady it 
and to limit rotation. 
(Cotton's Dislocations 
and Joint Fractures, 
W. B. Saunders Co.) 




Fig. 654. — Support to keep weight of bedclothes from 

foot in treating fractures of thigh and leg. Made 

from barrel hoops. (Cotton.) 



560 



TREATISE ON FBACTUEES 




Fig. 655a. 



Fig. 6556. 





1 


V- 
HH5 *-- 


■ •»•■;■ 

A J 1 


■ 




-ipi 



Fig. 655c- 



Figs. 6550-655^. — Vertical extension for the treatment of fractures of the femur in children. Fig. 655a: 
Adhesive plaster traction, overhead traction, weights and Bradford frame. Fig. 6556: Cotton bandage 
applied from the malleoli to the lower thigh; thigh surrounded by sheet-wadding layers and by coapta- 
tion splints and straps. Swathe to hold patient still upon Bradford frame is padded about frame and 
abdomen of the child. Fig. 655c: Method of slowly decreasing the angle at the hip- joint after union 

has occurred. 



FRACTURES OF THE SHAFT OF THE FEMUR 



561 



of these adjuncts permits the more frequent application of light massage 
and passive motion to the muscles and joints. These manipulations are 
believed to be valuable adjuncts to restoration of function. 



Fig. 656. 




Fig. 657. 




Figs. 656 and 657. — Another method of vertical extension by Bryant's method 

for fracture of the shaft of the femur, which may be used, as may that shown in 

other figures, in adults as well as children. 



In ordinary fractures of the shafts of the femur this modified Buck 
apparatus should be followed by a good result, and union should occur in 
from seven to nine weeks. The apparatus should then be removed and 
36 



562 



TREATISE ON FRACTURES 



replaced by a plaster spica including the pelvis, thigh and part of leg, 
and the patient gradually allowed up on crutches with a high shoe on 
the well foot. Weight-bearing should not be allowed for three to five 
months from the time of injury. The time depends somewhat upon the 
body weight of the patient and the type of fracture. A more comfortable 
form of ambulatory immobilization is some form of convalescent, but 
expensive, hip splint (see Fig. 659). 

In fractures of the upper third of the shaft with the lower end of the 
upper fragment in a flexed position and in abducted rotation, it is often 
impossible to maintain reduction by horizontal traction. It is then neces- 
sary to bring the lower fragment in line with the tilted upper one, main- 




Fig. 658. — Christen's suspension method for treatment of fractures of the shaft of the femur in children. 

tain the two fragments in this position, and use traction to prevent over- 
riding of fragments (Fig. 632). This may be accomplished by traction 
applied to the thigh partially flexed at the hip and encased in a plaster-of- 
Paris spica, which includes the pelvis, thigh, leg, and foot. The gypsum 
case is applied with the thigh in flexion, with slight abduction and some 
outward rotation with the leg flexed about 45 degrees on the thigh. This 
dressing is used for from at least four to six weeks; after this time it 
may be replaced, if union and position are good, by a plaster spica in 
the extended position without traction. After ten weeks the patient may 
be allowed to be out of bed on crutches, and weight-bearing may be per- 
mitted at the end of four months. If for any reason it is not considered 
advisable to use this form of apparatus, fair results may occasionally be 
obtained by the carefully watched double inclined plane with traction from 



FBACTUBES OF THE SHAFT OF THE FEMUR 



563 



the thigh, or, better, by the Nathan R. Smith anterior suspended splint 
of wire or Hodgen suspended wire splint combining suspension and 
traction with traction. Fractures in this region, if wisely treated, gener- 
ally give fair functional results, but there will be in some cases shortening 
and angulation unless they are treated by open operation. 

Fractures of the lower third of the femur are not all characterized 
by posterior displacement of the upper end of the lower fragment. In 
fractures without this posterior displace- 
ment of the lower fragment, good results 
may be obtained by the use of the already 
described Buck traction apparatus. 

Comminuted fractures of this region 
are best treated by the same dressing. 
When there is posterior displacement of 
the upper end of the lower fragment and 
it is found impossible to retain the frag- 
ments in good position, tenotomy of the 
Achilles tendon may be performed, if it is 
thought that the displacement is due to 
the pull of the gastrocnemius muscle. 
Good position may also be obtained by 
the use of a plaster spica dressing including 
the pelvis, thigh, leg and foot, applied with 
the thigh and leg in a position of flexion, 
and the use of traction from the lower 
part of the thigh and by the use of traction 
applied with the hip- and knee-joints flexed 
(Fig. 632). In all adult cases the normal 
anterior convexity of the femur, marked 
in muscular subjects, should not be for- 
gotten when applying support posteriorly. 
The suspended splints of Smith, Hodgen 
or the Thomas splint, as used in the recent 
war, are valuable. They had not been 
utilized in civil practice very much until 
made familiar by reports of army practice. 
In open, infected, and comminuted frac- 
ture they will be found especially con- 
venient and effective. The Balkan frame, or a substitute such as a 
gallows, may be readily made with saw and hammer to enable the surgeon 
to regulate the manner of suspension and obtain necessary traction and 
countertraction. Provision should be made for joint movements, active 
as well as passive, during the continuance of fixation of the site of fracture. 

Sir Robert Jones highly recommends the use of the Thomas knee 
splint for all fractures of the shaft of the femur. He is persuaded the 




Fig. 659. — Convalescent splint to be 
used in the treatment of fractures of the 
femur when the patient is first allowed 
up. Should be used with crutches. If 
the injured limb is raised from the 
ground in this manner by the thick sole 
shoe on the well limb, and the patient 
kept on crutches when walking, the 
splint need not be employed to protect 
the recently broken femur. A gypsum 
encasement is cheaper. 



564 TEEATISE OX FKACTUKES 

fault lies not in the way the fracture is set in the first instance, but in the 
fact that the thigh muscles subsequently contract and produce too much 
movement of the fragments, with overriding and shortening. He believes 
that if weight and pulley traction be used, as in Buck's method, the 
muscles of the thigh are suddenly relieved of tension every time the 
patient moves his body, and thereupon contract. In his opinion a rigid 
system of extension should be adopted, which results in muscles ceasing 
to resist in from twenty-four to forty-eight hours. His method is to fix 
the broken limb in a rigid apparatus from pelvis to foot, which gives trac- 
tion and countertraction ; then the patient can be moved, lifted, and 
nursed without the slightest fear of muscular action telescoping the frag- 
ments. Thus starting pains are unknown and the alignment of the thigh 
is as nearly perfect as possible. He likes the Thomas splint and intro- 
duced it into the Royal British Army Medical Service. A properly applied 
Bradford frame may meet Jones's requirements. 

The difficulties met in the treatment of fractures of the shaft of the 
femur in children are the frequency with which dressings are soiled by 
urine and faeces, liability to excoriations, and the ease with which dressings 
become displaced. Fracture dressings suitable for adults are consequently 
not always available. These troubles may be obviated and good anatomi- 
cal and functional result obtained by the Bryant vertical traction method 
(Figs. 656(7—658). Adhesive plaster strips, an inch or more in width, 
are applied from the point of fracture to one inch above the malleoli and 
continued two inches below the foot, where they are placed over a wooden 
perforated spreader three inches in length and about one inch in width. 
These strips are supplemented by three circular strips two inches in 
width, one at the seat of fracture, one below the knee, and the third one 
and a half inches above the malleoli, and by two one-inch strips applied 
diagonally from above the malleoli to the seat of fracture. This dressing 
is covered by a flannel bandage from above the malleoli to the upper limit 
of the thigh and the entire thigh surrounded by coaptation splints held in 
place by three webbing straps applied at the two extremities and middle of 
the splint. A thin rope is passed through the hole in the spreader and 
through the pulley of the overhead traction gallows, and sufficient weight 
used to just lift the gluteal region of the affected side off of the bed. 
Traction should be in a vertical direction. The coaptation splints are 
often unnecessary. The patient is then placed on a Bradford frame 
and held to it by a swathe including the chest and abdomen. The Bradford 
frame may often be omitted. This method of traction gives very satis- 
factory results in children up to ten or twelve years of age, and may be 
used for fractures of all parts of the shaft of the femur. Attention 
should be paid to the parts so as to prevent sagging of the leg and inward 
or outward rotation below the seat of fracture. Excoriations about the 
malleoli and buttocks should be avoided, and the coaptation splints should 
be readjusted from time to time. At the end of six to seven weeks the 



FRACTURES OF THE SHAFT OF THE FEMUR 565 

angle of traction may be slowly lowered, so that in the course of a week 
the horizontal position is attained, after which time a plaster spica includ- 
ing pelvis, thigh and leg may be applied and the patient allowed on 
crutches. Weight-bearing may be started at the end of twelve to fourteen 
weeks. During late convalescence an ambulatant hip splint should be 
used (Fig. 659), or the patient allowed to walk with crutches and a thick- 
ened sole and heel on the shoe of the well limb to prevent weight being 
thrown on the injured femur. 

It is probable that British surgeons had until the recent war obtained 
poorer results in the non-operative treatment of fractures than was the 
case in the United States, where long immobilization is less the rule than 
in Great Britain. Prolonged immobilization is a mistake in fracture treat- 
ment, as it prevents frequent examination and readjustment of fragments ; 
it tends to permit articular rigidity and muscular atrophy from which 
convalescence is slow. 

After the initial reduction under general anaesthesia and the application 
of a supposedly proper external fixation apparatus, daily examinations 
should be made to see the effect of the endeavor to prevent recurrence of 
displacement. Modification of the splinting appliances may be required to 
insure maintenance of the coaptation of the ends of the fragments. 
Later, when the callus has become only moderately firm, some readjust- 
ment may be made by the surgeon correcting angular displacement by 
manual manipulations. If a gypsum case has been used in the early treat- 
ment to maintain anatomical alignment, this straightening process may 
in some instances be carried out without removing the entire case. This 
is to be done by cutting a window through the plaster and gauze on the 
concave side of the limb. This will permit the bone to be bent into 
proper shape and a new portion of the encasement to be constructed 
over the opening to restore the rigidity of the gypsum cylindrical splint. 

Reduction of the fragments may be accomplished immediately, if 
general anaesthesia is employed and traction with countertraction applied. 
The traction should be aided by moulding with the hands to overcome 
lateral, anteroposterior, or rotary displacement. The traction in delayed 
reduction must be quite great. It may be made by the hands of assistants. 
The great traction necessary for immediate reduction, when the operative 
treatment with mechanical fixation is adopted, may be obtained with 
great satisfaction and ease by the use of the Levis plate and the com- 
pound pulleys. 

If gradual reduction is adopted, no general anaesthetic is required, as 
a rule, and the traction with countertraction is best made bv weigfhts 
fastened to a cord running over a simple pulley at the foot of the bed. 
The cord is fastened to a stirrup attached to the limb by strips of adhesive 
plaster extending up to the seat of fracture. Moulding to overcome lat- 
eral, anteroposterior, or rotary displacement is to be made with the hands 
after the traction weights have exerted their effect upon the overriding 



566 TREATISE OX FRACTURES 

fragments for about two days. The weight for such traction in a strong 
male adult should be probably about twenty-five to thirty pounds, though 
more may be required. The countertraction is well made by elevating 
the foot of the bed and passing a broad sheet under the perineum of the 
patient and fastening its ends to the head of the bed. There should be a 
firm cushion or block placed between the foot of the well limb of the 
patient and the footboard of the bed, in order that he may, by placing his 
foot against this block or cushion, prevent the heavy weights on the broken 
limb pulling him downward. 

The drum-tight movable frame, attached to the fracture bed by 
Dr. E. A. Bryant, of Los Angeles, to elevate the patient instead of 
elevating the foot of the bed, is very ingenious and simple. 

The best indirect or non-operative method of fixation is continuous 
traction with countertraction to correct overriding. This must be aided 
by some form of splint, such as sand-bags, boxes of bricks, or long boards, 
to prevent axial displacement if the limb is not suspended. It must at 
time be combined with abduction or elevation of the entire limb, and 
occasionally should be supplemented by a gypsum encasement. A com- 
bination of suspension and traction, with opportunity for massage and 
also mobility of the joints, is a very valuable method of dealing with 
shaft fractures. 

There are certain details in the treatment of fractures of the shaft 
of the femur, whether the method adopted be the operative or non-opera- 
tive, which demand attention. These, unfortunately, are often overlooked. 

The bed should be comparatively narrow, though not' sufficiently nar- 
row to make support, especially during abduction of the thigh, insecure. 
The frame and bottom of the bed should be rigid, and a spring mattress 
should never be tolerated. The beds often used in American hospitals for 
fractures of this sort, with wire mattresses and sliding boards placed 
underneath the mattresses, are unreliable. 

The bedpan should be wedge-shaped at its upper end. The douche 
bedpan with' high rim, frequently used in recent years, is probably a fre- 
quent source of deformity in fractures of the femur. A large soup plate 
answers very well for receiving the faecal masses. It may be satisfactorily 
employed, if a urinal is used before the contents of the bowels are evacu- 
ated. In certain hospitals the nurses and orderlies use the high-brim 
douche pan, often called a bedpan, for receiving the alvine discharges of 
patients with fractured femur. This article was originally invented for 
giving vaginal douches and large rectal enemas in abdominal surgery. 
It should be absolutely prohibited for patients with fractured femur 
treated by permanent traction, by means of pulley and weights. For an 
orderly or nurse, or even two nurses, to attempt to lift a patient of the 
kind mentioned an inch and a half or two inches above the bed to slip 
this douche, pan under his buttocks is almost equivalent to deliberately 
displacing the fragments. 



FRACTURES OF THE SHAFT OF THE FEMUR 567 

To obtain good end results the surgeon himself must know the anat- 
omy of the displacing muscles as well as that of the broken bone. He 
should examine his patient daily for, say, the first two weeks, then bi- 
weekly for three weeks, and then weekly for four weeks. This seems 
almost essential, in order to detect any deviation in the position of the 
fragments and to see that the assistants are giving the patient the careful 
surgical nursing requisite. There can be no absolute rul-e in regard to the 
number of visits the surgeon must make, but the frequency of his exam- 
inations should be very nearly that which has just been mentioned as a 
working rule. 

When the patient is to be moved or turned on the side for the treat- 
ment of possible bed-sores, two attendants are needed as a rule, one of whom 
should be sufficiently acquainted with the mechanics of the treatment 
to keep up the traction in the proper direction, when, it is relaxed to per- 
mit such changes of the patient's position. If the patient is to be removed 
to an X-ray laboratory, the extension should be kept up during the trans- 
portation, and the X-ray pictures should be taken while the usual amount 
of traction employed in the treatment is maintained. If the patient is 
under treatment in a hospital, the resident physician responsible for his 
welfare or the nurse having charge of the case must have some mechanical 
idea of the nature of the injury and its treatment, and know how to apply 
the apparatus and bandages properly. 

The non-operative method and the gradual method of reduction by 
traction are usually associated, because overlapping of fragments nearly 
always occurs. 

The non-operative method with continuous traction and countertrac- 
tion is the method of treating fractures of the femur which generally 
should be adopted. There are some exceptions, when the operative 
method with direct fixation should be employed. The non-operative 
method should be employed where the fracture is readily reduced and 
coaptation of fragments is easily maintained. This means in the great 
majority of cases, provided that the surgeon has the necessary accessories 
mentioned above and is willing to give the kind of attention to the case 
that has been described. When the medical practitioner has not been 
trained in modern aseptic methods or has had little experience in treating 
deep septic wounds of bone, the non-operative method is the only method 
that should be adopted by him. When the medical practitioner in charge 
of the case has no time to see the patient frequently or is apt to be careless 
of his professional responsibilities, the patient is safer under the non- 
operative treatment than the operative, though the end result is not likely 
to be a perfect one. When the nursing between the practitioner's visits is 
fairly satisfactory, or can be made so, the non-operative method will 
usually bring good results, if the practitioner has the qualifications, mental 
and moral, mentioned and obtains the necessary accessories described. 

The operative method and the immediate method of reduction are 



568 TREATISE ON FRACTURES 

usually associated, because, if the fracture is to be exposed by incision 
and stable coaptation is to be made, it is necessary to reduce the fragments 
as a preliminary to the fixation of them. 

The operative method should be employed when the fracture can not 
be satisfactorily reduced, or, if it can be reduced, when maintenance of 
coaptation is impracticable, provided, however : (a) That a trained aseptic 
surgeon does the operation and has charge of the after-treatment; (b) 
that the operation is done where asepsis can be obtained and maintained; 
(c) that the surgeon and attendants have time and willingness to be on 
the alert for aseptic symptoms and to devote their energies to averting 
their consequences. 

Direct fixation should be done in fractures of the shaft of the femur 
just below the small trochanter, in very oblique fractures of the shaft, and 
in fractures of its lower end with more frequency than in other fractures 
of that bone. As stated above, it should be attempted only by a skilled 
modern surgeon who can assure the patient of skilful, constant, and 
judicious after-treatment. 

The operative method is seldom needed in other fractures of the 
femoral shaft, and not always in these if the medical practitioner knows 
the anatomy of and the mechanical problems presented by the injury, 
gives proper attention to the case and supplements the want of knowledge 
of the other attendants upon the patient by his own surgical acumen 
and vigilance. 

The operative treatment of fracture of the femur at times may give 
better functional results and less deformity than the non-operative. It 
should be undertaken, however, with great caution in the average Ameri- 
can hospital, because of the imperfect organization of many of these insti- 
tutions. The short terms of unsalaried individual surgeons, the imperfect 
training and service of resident physicians and nurses, 'and the dangers of 
prolonged anaesthesia in ill-trained hands make this method too risky 
when it is compared with the non-operative. 

It is, of course, true that these factors militate somewhat against 
satisfactory end results in non-operative cases also, but the danger to life 
is much less in the latter instance. 

Results. — The report of the Committee on Treatment of Simple Frac- 
tures of the British Medical Association shows the following results : 
Non-operative : upper third of femur in 3 cases, good anatomical and 
good functional results in 3 cases ; middle third 27 cases, good anatomical 
and good functional results in 25 cases; lower third, 2 cases, good ana- 
tomical and good functional results in 1 case. Average duration of 
incapacitation, number of cases in which period was stated in fractures 
of shaft of femur 196 cases, average number of weeks of incapacitation 
16.5 under fifteen years; over fifteen years, number of cases 179, number 
of weeks of incapacitation 33.6, and number of cases in which incapaci- 
tation was permanent 21, — 1 1.7 per cent. The number of operative cases 



FBACTUEES OF THE SHAFT OF THE FEMUR 



569 



was so small that comparison was not possible. A consideration of the 
good results of the upper middle and lower thirds according to age periods 
was as follows: upper third, under fifteen years 95 per cent., between 
sixteen and forty-rive years 70 per cent., and over forty-five years 31 
per cent.; middle third, under fifteen years 97 per cent., sixteen to forty- 



Fig. 660. 



Fig. 661. 




CC 








o 


30 


m 


m i 


■ '"» 


\ 


• ** ' 1 


I ^ 


; 1 


1 '£ 



: 



\\ 



Fig. 660 — Supracondylar fracture of femur. Note the posterior displacement of the upper end of 

the lower fragment. 

Fig. 661. — Drawing to show the pull exerted by the gastrocnemius muscle in producing posterior 

displacement of upper end of lower fragment. (Made after rontgenogram, Fig. 660.) The liability 

to injury of the popliteal vessels and nerve is shown. 

five years 58 per cent., over forty-five years 32 per cent. ; lower third, 
under fifteen years 94 per cent., sixteen to forty-five years 68 per cent., 
and over forty-five years 40 per cent. Some statistics on this point from 
the recent Reports of the Committee of the American Surgical Association 
on the Treatment of Fractures will be found instructive. 



570 



TREATISE ON FRACTURES 

Fig. 662. Fig. 663. 




Fig. 662. — Comminuted supracondylar fracture of the femur. 
Fig. 663. — Comminuted supracondylar fracture of the femur. Note overriding of fragments and 

callus formation. 



Ftg. 664. 



Fig. 665. 




Fig. 664. — Supracondylar fracture of the femur. Union with lateral overriding and rotary deformity. 
Fig. 665. — Comminuted supra-intracondylar fracture of the femur. Anteroposterior view. (See 

Fig. 666.) 



FRACTUKES OF THE SHAFT OF THE FEMUR 



571 



Fractures of the Lower End of the Femur 

Fractures of the lower end of the femur are of interest on account of 
their comparative rarity and the complications that may be present. The 
difficulty of controlling the lower fragment is sometimes great, because 
of the line being near the knee-joint. The involvement of the joint cavity 
by the line of the fracture running into it or the occurrence of coincident 
damage to the cartilages, ligaments, and synovial membrane will modify 
the symptoms, treatment, and prognosis of fractures in this region. In 
rare instances small pieces of bone may be torn off the femur or tibia 
by traumatic strain on the crucial ligaments within the knee-joint. The 
line of fracture may be in the shaft just above the condyles, the supra- 
condylar fracture ; at the same time this line may connect with one run- 



Fig. 666. 



Fig. 667. 










Fig. 666. — Comminuted supra-intracondylar fracture of the femur. Lateral view. (See 

Fig. 665). 
Fig. 667. — Supracondylar fracture of the femur in a child aged 3 years. 

ning down between the condyles, separating them, causing intercondylar 
T- or Y- fracture. Either the internal or external condyles may alone be 
separated from the remaining portion of the bone, or there may be a 
complete separation of the lower epiphysis of the femur. The last con- 
dition is only observed before the twentieth year. Another rare form of 
fracture is the separation of small cortical portions of bone from the 
surface of the internal or external condyle due to strain on the ligaments, 
the so-called " sprain-fracture." The most typical fractures are the 
oblique fractures of one or both condyles and the irregular T- or Y- frac- 
tures, in which the two condyles are separated from each other and from 
the shaft of the bone. 



572 



TEEATISE OX FBACTURES 



Fig. 668. 



Fig. 669. 



Supracondylar and Intercondylar Fractures (Figs. 660-669). — Sim- 
ple supracondylar fractures differ but little from low fractures of the 
lower third of the femur, except in the position of the line of fracture, 

and will not be here differ- 
entiated. When, however, they 
are associated with a split of 
the lower fragment by a frac- 
ture line running from the 
transverse line through the in- 
tercondylar notch, the clinical 
picture is entirely different. 

Etiology. — The cause of 
these fractures is severe vio- 
lence, either direct or indirect, 
such as a blow upon the knee, 
a fall upon the knee from a 
height, or perhaps a violent im- 
pact with torsion transmitted 
from foot to femur. The 
mechanism of the intercondy- 
lar variety is that the splitting 
of the lower fragment results 
from the wedge-like action of 
the lower end of the upper 
fragment separating the lower 
fragment into two or more 
parts and producing the typical 
T- or Y-shaped fracture. The 
line of fracture across the shaft 
is generally oblique, though at 
times transverse, and that of 
the lower fragment is more or 
less vertical and in an antero- 
posterior plane. Comminution 
of fragments may be present, 
and the lower end of the upper 
fragment may pierce the soft 
parts and produce an open frac- 
ture. The lower fragments are 
displaced posteriorly and 
laterally. 

Symptoms. — The symp- 
toms of intercondylar fractures are loss of function, false motion, bony 
crepitus, widening of the condylar region, separate mobility of the two 
condyles, at times the sinking in of the patella between the two condyles, 




Fig. 668. — -Femur, right; fracture of the lower shaft. 
Union with anterior deformity and shortening. The frac- 
ture occurred 8 cm. above the joint and was nearly trans- 
verse. The lower fragment passed backward, upward, and 
to the outer side, and union has occurred in that position. 

(Mutter Museum, No. 1397.070.) 
Fig. 669. — Femur, left; comminuted intercondylar frac- 
ture. Union with deformity (plaster cast). The condyles 
are split so that the outer fragment is the smaller. The 
shaft was broken obliquely immediately above the con- 
dyles, from behind, downward, and forward, the fragments 
compressing the condyles passing upward and backward. 
The lower portion of the shaft was split. A fragment 
17 cm. long, composing nearly the entire thickness of the 
shaft, has united in a bad position. It points downward 
and outward and presents an anterior prominence. In its 
union with the condyles the latter has rotated outward 
30 degrees. (Mutter Museum, No. 1397.069.) 



FRACTURES OF THE SHAFT OF THE FEMUR 



573 



shortening of the extremity, and prominence of the lower end of the upper 
fragment anteriorly. Sometimes fixation in, and at times puncture of, 
the soft parts by a sharp upper fragment occurs. In addition there are 
great swelling, ecchymosis, joint effusion or hemorrhage, and local evi- 
dences of direct injury to the soft parts. 

Complications. — The complications of intercondylar fracture are 
arthritis, injury to the popliteal artery and vein, the internal and external 
popliteal nerves (Figs. 670 and 671), and perforation of the soft parts 
by sharp fragments of bone. An intra-articular distention with synovial 
fluid or blood may be great and require aspiration or even incision. 



Fig. 670. 



Fig. 671. 





Figs. 670 and 671. — Fracture of internal condyle of femur. Anteroposterior and lateral views. 

Prognosis. — The prognosis in supracondylar and intercondylar frac- 
tures is not as serious as regards life as might be supposed. Damage may 
happen to artery and nerves in the popliteal space, but Cotton's opinion 
that it is not so very common seems to be correct. Imperfect function 
of the knee-joint may arise if good replacement of fragments is over- 
looked. The degree of functional restoration will depend upon the per- 
fection of reduction of fragments, the character of fragmentation, and 
the subsequent amounts of callus formed. Cases of intercondylar breaks 
in which good apposition of fragments is secured without widening of 
fragments and little joint callus, should be followed by fair functional 
result. The usual problem in supracondylar cases is to overcome shorten- 
ing and to see that the backward displacement does not put the patella in 



574 



TEEATISE OX FEACTUKES 



a bad relation to the lower end of the upper fragment in front of 
the knee-joint. 

Treatment. —Intercondylar lesions call for thorough reduction of 
fragments. General anesthesia should be used, and reduction accom- 
plished by steady traction combined with manipulation and lateral pres- 
sure. Tenotomy of the tendon of Achilles may lessen the displacing 
influence of spasm of the gastrocnemius muscle. The action of the popli- 
teus and the gastrocnemius muscles in supracondylar fractures sometimes 
rotates the lower fragment backward as in low fractures of the shaft. 





v 




Fig. 672. — Separation of the lower femoral epiphysis. Lateral and anteroposterior views. 

Characteristic deformity with the lower end of the diaphysis displaced posteriorly. Before 

reduction. (See Fig. 673.) 

This action is perhaps not as common as is sometimes alleged. The sug- 
gestion of F. Cortors, that theoretically mutual impaction of the condylar 
fragments with mallet and sand-bags is indicated after the best practical 
reduction has been obtained, may be of some use in lessening the subse- 
quent production of intra-articular callus. A bone peg or a metal nail 
might be subcutaneously driven through the condyles to hold them to- 
gether. Retention of fragments in their normal position may best be 
accomplished by the Buck traction apparatus, combined with posterior, 
internal and external lateral splints, and from ten to twenty pounds of 
weight. The suggestion of Robert Jones that the Thomas knee splint be 
used is worthy of thoughtful consideration. Immobilization should con- 
tinue for six to eight weeks, followed by the use of a suitable leg brace 



FBACTUBES OF THE SHAFT OF THE FEMUR 575 

or gvpsum-gauze encasement. When there is marked tendency toward 
displacement, traction should be made with the hip- and knee-joints flexed. 

Fractures of Either Internal or External Condyles (Figs. 670 and 
671 ). — Fracture of a singlecondyle is a very rare injury. Very few cases 
have been reported. 

Etiology. — These fractures may be the result of direct violence, and 
usually are due to forced abduction or adduction of the knee, to a twisting 
of the leg, or to direct force transmitted through; the head of the tibia 
toward the involved condyle. The line of fracture is usually oblique, run- 



v m \ 



X 



¥ 



Fig. 673. — Separation of the lower femoral epiphysis. Lateral and anteroposterior views. 
Fragments reduced. (See Fig. 672.) 

ning upward from the intercondylar notch for a considerable distance, 
producing a sharp spear-pointed fragment ; the line may be very short and 
end just above the condyle, or at the edge of the articular cartilage. 

Symptoms. — The symptoms consist in localized pain, tenderness, swell- 
ing, ecchymosis, effusion into the knee-joint, a valgus or varus position of 
the leg at the knee-joint, crepitus, and at times a moderate degree of dis- 
placement posteriorly and upward of the detached fragment. 

Prognosis. — The degree of function will depend upon the accuracy 
of reduction and the amount of intra-articular callus. Function may be 
expected to be somewhat impaired. 

Treatment. — Reduction may generally be accomplished by restoring 
the leg to its normal axis with the thigh, thereby controlling the position 



5 76 



TREATISE OX FRACTURES 



of the detached fragment by the action of the lateral ligaments. Immo- 
bilization should be obtained by a posterior splint with a pad placed above 
the fractured condyle and pressure by adhesive plaster. If there is little 
displacement of the fragment the extremity may be immobilized in a 
plaster dressing. At the end of three to six weeks passive motion may 
be begun, and at the end of twelve to sixteen weight-bearing may be 
carefully attempted. 

Separation of the Lower Femoral Epiphysis. — The lower epiphysis 
of the femur includes the entire articular surface of the lower end of the 

bone. It is the largest epiphysis of the 
body, and unites with the diaphysis from 
the twentieth to the twenty-first year. 
Traumatic separation of the epiphysis is 
most frequently observed about the tenth 
to twelfth year of life. 

Etiology, — Separation of the lower 
femoral epiphysis results from great vio- 
lence (Figs. 672-674), and as a result of 
abduction or hyper extension of the knee. 
The most frequent cause is the catching of 
the leg in the spokes of a rapidly revolv- 
ing wheel. 

The line of separation definitely fol- 
lows the epiphyseal cartilage, to which is 
at times attached small fragments of the 
diaphysis. At times considerable stripping 
of the periosteum of the diaphysis occurs. 
The lesion, by reason of the violence re- 
quired to produce it, may be complicated 
with an open wound. The usual deformity 
is an anterior and lateral displacement of 
the epiphysis with, at times, rotation of 
the epiphysis upon a bilateral axis. This 
is considered by some authorities to be 
due to the pull of the gastrocnemius 
muscle inserted on the diaphysis, but in all probability it is due to the 
primary violence plus the pull of the extensor thigh muscles. 

Symptoms. — The symptoms of separation of the lower femoral 
epiphysis are the history of injury, great swelling, tenderness, and signs 
of severe local injury about the knee-joint, abnormal mobility at the 
knee-joint, soft cartilaginous crepitus when it is possible to bring the 
fragments into contact, marked deformity, and loss of function. 

The condition should be distinguished from supracondylar fracture 
and dislocation of the knee-joint. In supracondylar fracture crepitus is 
bony in character, the line of fracture is above the adductor tubercle, 




Fig. 674- — Femur; separation of lower 
epiphysis. Shows normal epiphyseal lines 
of tibia and fibula. Case of Dr. R. H. 
Harte. (Mutter Museum.) 



FRACTURES OF THE SHAFT OF THE FEMUR 577 

while in dislocation the disturbed relation of the tibia with the femur 
will generally be evident. In no other fracture is a radiogram of more 
importance for the determination of the exact lesion present. Examina- 
tion and reduction should be made under general anaesthesia. 

Complications. — The complications of epiphyseal separation are rup- 
ture or compression of the popliteal artery or vein, injury to nerves, and 
external wound causing an open fracture. Rupture of vessels may be in- 
complete, with resulting aneurism, while complete laceration of the vessels 
may give rise to severe hemorrhage and pressure gangrene. Contusion or 
pressure of the vessels may result in gangrene, and less frequently in throm- 
bosis. Especial attention should be given to the color of the limb below 
the seat of fracture, and the presence or absence of pulsation below the 
seat of injury in the popliteal and tibial arteries should be carefully noted. 

Prognosis. — If reduction of the displaced epiphysis is readily accom- 
plished, apposition of fragments maintained, and no vessel injury be pres- 




Fig. 675. — Foot drop from epiphyseal fracture of lower end of femur and contusion of external peroneal 
nerve. The projection of the lower fragment backward can be seen at the outer part of the popliteal 

space. (Author's case.) 

ent, union should be prompt and functional recovery perfect. From the 
lack of reported cases it is evident that separation of the epiphysis is not 
often followed by failure of subsequent development and shortening of 
the limb. When the epiphyseal separation is accompanied by laceration 
of large vessels, amputation is often a necessary result. 

Treatment. — In anterior displacement of the epiphysis reduction may 
usually be accomplished, under anaesthesia, by flexion of the thigh and leg. 
An assistant should make steady traction on the flexed leg in a line down- 
ward and at right angles to the long axis of the femur. The surgeon 
then grasps the lower portion of the. thigh with the Angers of both hands 
in the popliteal space, and with, the thumbs presses downward and back- 
ward on the epiphysis. This manipulation should be done at once, it 
there is evidence of pressure on the popliteal vessels ; when reduction 
is accomplished, the leg may be brought into position of partial extension 
and immobilized on a posterior splint, gypsum, gauze, wood or metal, 
or in a gypsum moulded encasement (Figs. 676 and 6jy). Usually there 
37 



578 



TREATISE ON FRACTURES 



is no tendency toward displacement after reduction is accomplished, as 
the rough surfaces of the broadened end of the diaphysis and the epiphysis 
tend to remain engaged. If reduction tends to recur, the leg should be 
held flexed on the thigh at right angles and immobilized in a plaster 
dressing. Warbasse strongly advises, in anterior displacement, complete 
flexion to maintain the restored position of the epiphysis. He holds the 

joint in this forced flexion by bandages or 
gypsum encasement. He employs a similar 
method in low transverse fractures of the 
femoral shaft and in supracondylar breaks. 
This resembles the hyperflexion method used 
in the upper extremity. When reduction can- 
not be accomplished by conservative measures, 
an incision should be made on the external 
surface and reduction accomplished by lever- 
age combined with manipulation. 

In lateral and posterior displacements 
reduction can usually be accomplished by 
flexion, manipulation, and traction. Reduction 
is evident by the assumption of normal con- 
tour, soft crepitus at the time of reduction, 
and loss of tendency to recurrence. Union 
occurs in from four to six weeks. After this 
time, or even earlier, a knee splint may be used, 
passive motion adopted, and weight-bearing 
allowed at the end of twelve to fourteen weeks. 
If after open examination and reduction 
there is a tendency toward recurrence of the 
displacement, immobility should be obtained 
by direct fixation, preferably, perhaps, by a 
metal plate. As a rule, however, it is not ad- 
visable to use an internal method of fixation 
unless absolutely necessary, owing to the pos- 
sibility of inducing necrosis or causing inter- 
ference with the subsequent growth of the 
shaft at the epiphyseal end. 

Sprain-Fractures of the Lower End of the 
bowing "made Femur (Figs 678 and 679).— This rather in- 

("Pirrc f\no Q-nH \ O / IS/ 




Fig. 676 

femoral epiphysis 



Separation of the lower 



after rontgenogram. (Figs. 672 and 
673). Note the pull exerted by the 
gastrocnemius muscle (.4) in produc- 



: frequent form of fracture is a tearing off" of a 



mg 



posterior displacement of 
lower end of the diaphysis. 



the 



small part of the cortex of the bone in the 
region of the internal epicondyle, the adductor 
tubercle or the external epicondyle, or at the attachment of the tendon of 
the adductor magnus, the tendons of the gastrocnemius muscle, or at the 
point of attachment of the lateral ligaments. 



FRACTURES OF THE SHAFT OF THE FEMUR 



579 



Etiology. — While direct violence may be the cause of a few of these 
fractures, the majority result from strain brought upon the attachment 
of tendons and ligaments, and result in a tearing off of irregular portions 
of bone of varying size. 

Symptoms. — The symptoms resemble those of a severe sprain of the 
knee-joint. There are severe pain, localized tenderness on pressure, ecchy- 
mosis, and an effusion of serum or blood within the knee-joint. The 
patient complains of a considerable loss of function due to* pain and the 
effusion ; strain brought upon the attachment of the involved tendons by 
a forced varus or valgus position increases this pain (Figs. 680 and 681 ) ; 
at times crepitus is detected and the presence of a small movable fragment 




Fig. 677- — Method of reduction of separation of the lower epiphysis of the femur. 

may become evident on painstaking examination. After union has taken 
place, there may develop, particularly when the fragment has been de- 
tached by the pull of the adductor magnus tendon, an ossifying myositis 
of the involved tendon and muscle. 

Prognosis. — After adequate rest and subsequent careful massage, 
function should be fully restored. 

Treatment. — This consists almost entirely of immobilization in plaster 
or on a posterior splint for four to five weeks until union is firm. This 
should be associated with massage, baking, and passive motion ; and later 
the patient should be encouraged to use the parts. On account of the 
smallness of the detached fragment open operation with direct fixation 
is rarely demanded. 

Occasionally after a sprain-fracture occurring at the region of attach- 
ment of the adductor muscles, ossification in the substance of the muscle 
(myositis ossificans traumatica) may occur. This is due to the deposit of 
bone cells from the detached periosteum (Fig. 682). 



580 



TREATISE ON FRACTURES 




FRACTURES OF THE SHAFT OF THE FEMUR 



581 



Summary of Non-operative Treatment 

Firm, level mattress without springs. 

Upper End of Femur. — In aged, handle with gentleness and care lest 
impaction be broken up. Do not attempt to obtain preternatural mobility 
or crepitus. Treat as fracture of neck, until X-ray or result disproves 
diagnosis, with Buck's longitudinal traction of about 6 to 10 lbs., and lat- 

Pig.68o. 




Fig. 680. — Method of determining abnormal mobility in fracture of the external condyle of the femur 

by a forced varus position. 

Fig. 681. 








Fig. 681. — Method of determining abnormal mobility in fracture of the internal condyle of the femur 

by a forced valgus position. 

eral support on both sides of injured limb. Some lateral traction below 
trochanter may be added. 

When diagnosis of fracture of neck is established, continue same 
method if patient bears confinement in bed well. If patient loses ground 
in general health, treat patient rather than fracture and let him carefully 
assume sitting posture, even out of bed. 

Points that should be observed in fractures of femur while in frac- 
ture apparatus : 

A line drawn from anterior superior spine of ilium through centre 
of patella to inner side of internal malleolus of tibia indicates that there 



582 



TREATISE ON FRACTURES 



is no improper rotation of the lower fragment at the point of fracture. 
Slight abduction of limb is advisable in shaft fractures and slight 
e version of foot is normal when patient lies on back. The weight of the 
bed coverings should not be allowed to increase the eversion of the lower 
fragment; a wire or wooden frame should be placed over the foot to 

support the blankets. Too great 
eversion may be prevented by 
means of a broad strap of adhesive 
plaster attached to the calf of the 
leg and then carried over the top 
of the sand-bag or splint at the out- 
side of the limb and fixed in that 
position. 

Buck's traction stirrup some- 
times is dragged by the traction 
weight down the sides of the limb 
by reason of the adhesive plaster 
becoming softened by the patient's 
bodily heat. This may be avoided 
by using pure rubber plaster and 
turning down the upper ends be- 
fore applying the last turns of the 
bandage to the thigh. A ring made 
of twisted oakum is much better 
under the heel than cotton for the 
purpose of preventing pressure 
sores. 

In Young or Middle-aged. — 
May cautiously endeavor to obtain 
crepitus and abnormal mobility, 
using little force, but not suddenly. 
When X-ray confirms diagnosis 
and shows character of fracture 
lines, endeavor to reduce fragments 
and obtain proper coaptation by 
cautious flexion and full abduc- 
tion, using general anaesthesia as 
an adjunct to the manoeuvres. 

Use Buck's longitudinal Pac- 
tional method horizontally or in abduction with stable countertraction ; 
lateral traction outward below trochanter in addition may be wise; or 
Whitman's complete abduction method for both legs by means of a 
gypsum-gauze encasement, confining both sides from nipple line to 
below knees. 

Shaft of Femur. — Subtrochanteric. — After reduction under ether and 




682. — Myositis ossificans traumatica following 
strain of adductor muscles. Note ossification in 
substance of adduction muscles at its point of attach- 
ment to the femur. 



FRACTURES OF THE SHAFT OF THE FEMUR 



583 



study of lines of break, put up fracture with, hip partially flexed and the 
thigh somewhat everted and abducted to keep the upper and lower frag- 
ments coapted. Make traction in axis of thigh while in this posture by 
Buck's method with pulley placed high over lower part of bed, or with 
limb on an inclined plane, or with an anterior wire splint properly sus- 
pended to give traction in the needed direction. 

A gypsum-gauze encasement, including lower chest, abdomen, both 
hips and thighs, the opposite thigh lying horizontal, may be added to the 
traction appliance. 

Middle. — Reduction under ether, locking fragments if possible. 




Fig. 683. — Nathan R. Smith's anterior suspended wire splint for fractures of femur. 



Buck's longitudinal traction with sufficient weight — 15 to 40 pounds — not 
omitting stable countertraction, and lateral support. Traction may need 
to be a little above the horizontal axis of the normal limb. Remember the 
anterior arching of the femur. Coaptation splints or encasing contour 
splint about the broken region of the shaft may be necessary, especially 
in comminuted or double breaks. Suspended anterior wire splint may 
be best method (Hodgen's splint) or Taylor wire splint with traction 
in association with mobility of joints during the fixation of fragment. 
Watch progress with skiagrams. 

Lower end of the femur, including supracondylar fractures. Reduc- 
tion, Buck's longitudinal traction, and lateral support. Perhaps pos- 



584 TEEATISE OX FRACTUEES 

terior popliteal support with splint needed, or suspended wire splint, or 
gypsum encasement. Traction with Steinmann nail or ice tongs grasp in 
condyles is often used instead of depending upon adhesive plaster or glue 
for applying traction with weights and a pulley. 

In all fractures of femur avoid weight-bearing for several weeks 
after the union is believed to be solid. When consolidation is believed to 
be assured, at the end of about six or eight weeks' treatment, a gypsum 
encasement may usually be applied and the traction and other fixation 
apparatus discarded. Crutches may then be cautiously used, if a high 
sole shoe on the foot of the uninjured limb is worn. The injured limb 
thus cannot be used by the patient for bearing his weight in walking. The 
danger of bending the broken femur at the seat of the united fracture 
should be averted for a month or so longer. During the wearing of frac- 
ture apparatus the limb should be inspected daily for about two weeks 
to see that apparatus is accomplishing its purpose. Readjustment and 
removal with reapplication will occasionally be necessary. Bed sores from 
pressure must be averted or treated. 

The Nathan R. Smith suspended anterior splint, valuable in many 
fractures of the neck and shaft of the femur, and sometimes satisfactory 
for use in subtrochanteric and supracondylar fractures is a long, narrow 
rectangle made of two parallel rigid iron rods connected at the ends by 
similar pieces of metal. The splint must be long enough to extend about 
four or five inches above the hip-joint and beyond the toes when the ankle- 
joint is extended. The rods are sufficiently flexible to permit slight bend- 
ing under strong force at points corresponding to the patient's hip, knee 
and ankle. The amount of flexion must also be altered in accordance with 
the direction of the suspension and traction which the surgeon desires to 
maintain for the proper cure of the fracture. At an appropriate point 
between the knee and the hip and between the knee and the ankle a 
U-shaped strong metal rod is connected with the parallel sides of the splint 
for attaching ropes by which the splint with the injured limb may be 
suspended to an attachment above the bed. 

In use as a splint support a gutter or sling is made by loosely weav- 
ing a strong muslin bandage from side to side. This is to be made 
sufficiently loose to fit the patient's thigh and leg when the limb is laid in 
the trough, and is fixed there by a circular or spiral and reversed bandage. 
The ropes to suspend the leg and thigh are then attached to the U-shaped 
fixtures on the splint and from these a third rope carried to the point of 
support above. The principle of this fracture dressing is to prevent 
motion at the point of fracture and to permit traction in a vertical or 
oblique direction. This varying direction of traction is to be secured 
by altering the point at which the suspending cord is attached to the 
support above and its amount is changed by increasing or decreasing the 
weights. The countertraction is obtained by using the weight of the 
patient's buttocks and trunk as he lies in bed. By elevating the splint 



FRACTURES OF THE SHAFT OF THE FEMUR 585 

and limb above the mattress of the bed the desired amount of counter- 
traction is secured. 

In fractures of the upper part of the femur, for the proper treatment 
of which it is necessary to steady the hip-joint, the portion of the sus- 
pended rectangular splint is firmly fastened by a swathe to the pelvis and 
abdomen. The foot in a similar way in the position of dorsal flexion 
must be fixed by bandages to the lower end of the splint which projects 
beyond the toes. 

The Hodgen splint, which is also an anterior suspended splint, is a 
modification founded on very much the same principles as the older 
Nathan R. Smith splint. Both of these fracture appliances may be used 
with satisfaction for some fractures of the bones of the leg as well as for 
fractures of the femur. 

The Thomas hip splint, often used in treatment of fractures of the 
femur, is made from an iron bar and consists of a long shaft to extend 
from the mid-dorsal region almost to the ankle. It has riveted to it four 
bands of easily bent iron to embrace the chest, pelvis, the thigh and the 
calf. The main stem is bent to conform to the curves of the back and the 
buttocks and is applied on the side of the spines of the vertebrae corre- 
sponding with the injured lower extremity. The bands which are to 
encircle the chest, pelvis, thigh and calf are sufficiently flexible to be 
easily bent around these portions of the body and limb and nearly but 
not quite meet in front. The rigid bar for the support of the fracture 
itself can be bent by using a great deal of force which may need to be 
done by supplementing the operator's manual strength with strong for- 
ceps. In this manner the splint is made to fit the patient under care. 

Modifications of these splints, the Smith, the Hodgen and the hip 
splint of Thomas and the somewhat similar splint used in some fractures 
of the thigh and leg, called the Thomas knee splint, may be easily adapted 
to have a combination of suspension and greater traction than that 
ordinarily given. The Thomas splint may be made with a ring to bear 
on the tuberosity of the ischium and two parallel bars from hip to sole. 

The Bradford Frame 

The Bradford frame consists of an iron rectangular frame made 
of rigid gaspipe or similar material large enough to extend from 
above the patient's head to below his feet. It has strong canvas stretched 
from side to side, leaving an opening beneath the buttocks. The patient's 
trunk is attached to the upper portion by bands or straps at the hips 
and shoulders. Immobilization of the fracture and traction can then be 
applied without danger of its displacement by the patient moving about 
in bed. The frame with the patient attached is laid upon the mattress 
on an ordinary surgical bed. The advantage of the Bradford frame is 
that it makes it easy to lift the patient from bed to bed or from bed to 



586 TREATISE OX FRACTUBES 

stretcher without danger of interfering with the immobilizing apparatus 
necessary for fixing the fracture. 

The divers appliances which need attachment to the bed itself or to 
the walls of the room, such as pulleys, etc., must, of course, be temporarily 
disconnected when the patient on the rigid frame needs to be transported 
from one place to another. 

Operative Treatment of Fractures of the Neck of the Femur. 

When it is impossible to keep the fragments in good position or 
to obtain reduction of fragments, nailing or pegging the fracture is a 
proper procedure. If the surgeon is unable to reduce the fracture by 
manipulation the joint should be opened and reduction accomplished by 
a carefully planned aseptic operation. A bone peg made from a piece of 
tibia of the patient, or a metal nail or screw may be employed. When 
possible, subcutaneous, or a relatively subcutaneous operation, through 
a small incision made over the trochanter is less likely to be followed 
by complications than arthrotomy. When the joint has to be opened 
an incision may be made in front, beginning below the superior inferior 
spine of the ilium and running downward and inward. The operator, by 
pushing the sartorius muscle toward the pubes, will be able to feel the 
point of fracture and open the capsule. The displaced capital fragment 
may then be put into proper position with or without instruments. It is 
usually best done by carrying the thigh into extreme adduction. A small 
wound over the trochanter, a little less than two inches below the tip, 
indicates the point through which a nail or peg a little over three inches long 
may be driven into the bone through the long axis of the middle of the 
neck into the head, thus fixing the fragments. A bone peg should be used 
in a similar manner, but it will be necessary in the event of using such 
a graft, whether for a recent fracture or an ununited fracture, to pre- 
viously drill the trochanter and neck and head. The drill must be big 
enough to allow the bone peg to slip in with comparative ease. The 
external wound, which is small, is then closed. A Paris plaster dressing 
encases then the trunk from the nipple line to the toe. 



CHAPTER XXIII 

FRACTURES OF THE PATELLA 

Anatomy. — The patella is a large, flat, somewhat triangular sesamoid 
bone imbedded in the tendon of the quadriceps extensor muscle of the leg. 
It has two surfaces, an anterior, which is convex, roughened and separated 
from the cellulo-integument of the front of the knee by a bursa; and a 
smooth posterior or articular surface, covered by cartilage for about four- 
fifths of its extent. The remaining part is not in contact with the synovial 
membrane of the joint and is enveloped at its very tip by the ligament 
attaching the bone to the tubercle of the tibia. The synovial membrane 
of the knee-joint is attached to the upper and middle parts of the posterior 
surface of the bone. The upper end or base is broad and gives 
insertion to the tendon of the quadriceps extensor muscle. The lower 
end or apex gives attachment to the ligament of the patella. It is usually 
developed from a single centre of ossification, which appears about the 
third year. It may remain cartilaginous until the sixth year. Ossification 
takes place about the age of puberty. Occasionally there are two centres 
of ossification lying transversely. The essential factor in fracture of the 
patella is the extent to which the enveloping tendon is torn. In fractures 
of the lower part the joint is not opened as is the case in nearly all other 
fractures. This is because the lower fifth is not in contact with the synovial 
membrane of the knee. 

Surface Markings. — Relaxation of the extensor muscle allows palpa- 
tion of the entire border of the patella, and furnishes a demonstration of 
its mobility. In flexion of the leg the patella is carried downward over 
the condyles; in extension it is carried upward, so that in extreme exten- 
sion only the lower half of the patella is in contact with the condyles of the 
femur. Laterally there are sulci ; and on flexion of the leg the articulating 
surfaces of the condyles may be palpated. 

Statistics. — Plagemann's statistics from the Rostock clinic, based upon 
the' radiographic study of 1393 fractures, showed the patella to be frac- 
tured in 35 instances (2.51 per cent.). Of these 35 cases, the fracture 
involved the upper third 5 times, the middle third 22 times, and the lower 
third 8 times. In 17 instances the fracture line was transverse; 2 times 
there was a superficial tearing out of the bone at the apex of the patella, 
and 4 times there was a fracture at the base of the patella with a separation 
of a three-cornered fragment at the attachment of the extensor tendon. 
In 9 cases the fracture line was transverse, with more or less penetrating 
longitudinal or oblique fissures, and in 2 instances there were typical stel- 
late fractures. A clean longitudinal fracture was not observed during the 

587 



588 



TREATISE OX FRACTURES 



preparation of this classification, although later he observed two of this 
character and also saw two subperiosteal fractures. 

Etiology. — The etiology of the fractures in individual cases is often 
difficult to determine. Patients have difficulty in telling whether the 
fracture preceded the fall or was the result of it. As in other fractures,, 
this lesion may be due to direct force. Indirect forces have little oppor- 
tunity to act upon the patella because it is buried in the tendon of the 
four-headed extensor of the leg. Fractures due to muscular action are 
occasioned by sudden and forcible contraction of the quadriceps extensor 
muscle, occurring during a misstep in an effort to save oneself from 
falling, in the voluntary use of the leg, as in kicking or lifting a weight 
with the leg or back, or in resisting forced flexion of the knee. The patient 

may attribute the fracture to a fall upon 
the knee when in fact the fracture pre- 
ceded the fall, and local evidences of 
contusion of the region of the knee are 
absent. The laceration of the fibrous 
covering of the patella and the tears in 
lateral expansion of the capsule of the 
joint, accompanying the break, are evi- 
dently produced by severe muscular pull 
and not by a local direct violence. Early 
and late re fractures of a united patella 
mav also be occasioned by muscular 
action. Sometimes these fractures tear 
open an adherent skin over the former 
break and the muscular aponeurosis and 
o;ive rise to a readilv contaminated or 
infected open fracture. The synovial 
sac, being attached to the articular sur- 
face, and the overlying skin to the 
superior surface cause these re fractures to lay the knee-joint widely open. 
Otherwise infected fractures of the patella are rare, even in fractures from 
direct blows causing the comminuted irregular lines of fracture. 

Fractures by direct violence are due to impact of a fall upon the patella 
and to kicks and blows delivered directly upon the bone. Patellar fractures 
are rarely seen before the twentieth year, and are most frequently met 
between the thirtieth and fiftieth years. They occur rarely in children, and 
more commonly among male adults than in women. 

Varieties and Mechanism. — Fractures of the patella (Figs. 686-691) 
may be transverse, oblique, comminuted, longitudinal, subperiosteal : and 
anv of these forms may be closed or open. If open, infection adds obvious 
seriousness to the injury. Those caused by muscular action are usually 
transverse in direction and closed ; occasionally they are merely a tearing 
off of the upper or lower cortical portion of bone. Fractures by direct 




Fig. 684. — Fissure-fracture of patella without 
tear of muscle or aponeurosis. (Helferich.) 



FRACTURES OF THE PATELLA 



589 



violence are usually oblique, but are at times comminuted ; and occasion- 
ally they are accompanied by a wound, causing them to be open fractures. 

In transverse fractures the line may occupy the upper, middle or lower 
third of the bone, but is usually in the middle third. Fractures by direct 
violence may occupy any portion of the bone and be of any variety. 

Without entering into a discussion of the various theories of the 
mechanism of fractures of the patella, it may be stated that those pro- 
duced by muscular action occur while the knee is partially flexed. The 
patella then is held firmly by the quadriceps muscle and the ligament of 
the patella against the condyles of the femur, a sudden contraction of the 
quadriceps muscle acts forcibly on the upper edge of the patella and the 
bone is broken transversely at its point of contact with the condyles. 
The resulting line of fracture depends upon the degree of flexion of the 



Tendon of quadriceps extensor 




Ligamentum patellae 
Fig. 685. 



Ligamentum patellae 

-Right patella, anterior and posterior surfaces. 



knee at the time of fracture (Fig. 692). When the patella breaks, the 
aponeurosis and lateral expansion of the quadriceps tendon also may 
be torn by the muscular pull. The tear is of varying degree, from a slight 
tear in the aponeurosis over the patella to a complete rupture of both 
lateral expansions of the joint capsule. In fractures by direct violence 
there are, as a rule, very little separation of fragments, very little tearing 
of the fibrous aponeurosis over the patella, or of the lateral expansion 
of the joint capsule. Transverse fractures, in which the lateral expansion 
of the aponeurosis and the joint capsule are torn, show marked separation 
of the fragments. This is greatly increased by flexing the knee. The 
lower fragment remains stationary, due to its ligamentous connection 
with the tibia, but the upper fragment is displaced upward, unless the 
fibrous envelope has not been torn ; there may be separation amounting to 
from half an inch to an inch. Later this may be increased greatly by 
rapidly occurring joint effusion and intra-articular hemorrhage, and the 



590 



TEEATISE OX FRACTURES 



muscular contraction. Tilting of the fragments forward at the fracture 
line is quite usual. Lateral displacement is not common, the tilting may 
be great enough to turn the fracture surfaces toward the skin. 

Fig. 686. 



Fig. 687. 




I 



Fig. 686. — Incomplete transverse fracture of the patella. 
Fig. 687. — Transverse fracture of the patella, lower third. 



Fig. 688a. 



Fig. 6886. 




Fig. 688a. — Transverse fracture of the patella with marked rotation of the lower fragment. 
Fig. 6886.— Transverse fracture of the patella, middle third, with separation of the fragments. 

Symptoms. — The types to be described are those due to muscular 
action, which usually show more or less separation of fragments, and 
those caused by direct violence, which generally have irregular lines of 
break with little if any separation of the pieces. In the two classes 



FRACTURES OF THE PATELLA 



591 



the symptoms, the prognosis, the form of treatment and the end results 
are different. 

. The symptoms of fracture by muscular action, in which there are pres- 

Fig. 689a. Fig. 6&gb. 




Fig. 689a. — Incomplete transverse fracture of the patella, lower third; direct violence. 
Fig. 6896. — Transverse fracture of the patella, middle third. Marked separation of fragments. 



Fig. 690. 



Fig. 691. 





Fig. 690. — Transverse fracture of the patella, with moderate bony union. 
Fig. 691. — Old transverse fracture of the patella, upper third, with extreme separation of the 

fragments. 

ent separation of fragments and a transverse line of fracture in about So 
per cent, of cases, are sudden loss of power of extension at the knee, so 
that the patient cannot voluntarily straighten the flexed knee. Walking 



592 



TREATISE OX FRACTURES 



may be possible if care be taken to keep the tibia and femur in a straight 
line and the heel to the ground. Although at times he is able to extend 
the knee by swinging the leg with the thigh, he is unable to raise the foot 
from the bed when supine. Disability varies, however, with the amount 
of laceration of the tendinous aponeurosis surrounding the patella. The 
tendinous fibres of the vastus internus on the inner side and the prolonga- 
tion of the fascia lata on the outer side are not always completely torn; as 
a result limited extension of the knee may be possible. Pain not intense, 

tenderness on pressure, and marked 
swelling of the entire knee region 
anteriorly and laterally are found upon 
examination. This swelling is due to 
joint effusion and hemorrhage. It ex- 
tends outside the joint into the soft 
parts, and can be felt directly beneath 
the skin in the area between the frag- 
ments. The arthritis does not give rise 
to . acute pain so common in ordinary 
cases of arthritis of this joint because 
the rupture of the synovial sac attached 
to the inner surface of the bone pre- 
vents intra-articular tension. Ecchymosis 
may extend beneath the quadriceps 
femoris and under the skin of the thigh. 
The separated fragments may be felt 
distinctly; and as a rule there is a 
marked interval between them, forming 
a transverse cutaneous groove into 
which one or two fingers may be laid. 
Crepitus may be obtained, if the effusion 
is small and muscular pull has not sep- 
arated the fragments widely. This is 
readily developed by slowly pressing the 
fragments together and moving them 
laterally upon each other. This pro- 
cedure is somewhat painful, but establishes the diagnosis. Under ether 
the muscular contraction which causes the separation is easily overcome 
and crepitus is found without causing pain. 

In fractures by muscular action there are no local signs of con- 
tusion or abrasion of the soft parts, unless the patient falls directly on 
the knee after sustaining the fracture. 

The symptoms of fracture by direct violence are localized pain, tender- 
ness on pressure, the presence of a contused, abraded, or lacerated wound 
over the patella, effusion not only in the knee-joint but also in the pre- 
patellar bursa. The muscular attachments are not torn away and the 




Fig. 692. — Drawing to show the mechanism 
of fracture of the patella by muscular action. 



FKACTUKES OF THE PATELLA 593 

patella is shortened rather than divided transversely. The loss of function 
is not due to marked inability to extend the leg, as in fracture by muscular 
action, but is due to pain. Patients are able to bear weight on the leg, 
and in many cases may walk. As there is little separation of fragments, 
crepitus and mobility of fragments may be readily determined. There is 
effusion of synovial fluid and at times blood into the knee-joint. The 
character of the swelling is, however, different from that seen in fractures 
by muscular action, in that it is similar to that seen in acute synovitis and 
rarely extends into the surrounding soft parts. 

In vertical, subperiosteal, and cortical fractures the symptoms present 
may be only those of an associated traumatic synovitis and the true 
lesion only recognized by radiogram. Sometimes late ecchymosis over 
the bone and the development of a local swelling from callus may reveal 
the true character of the lesion. 

Differential Diagnosis.— Fracture of the patella should not be confused 
with rupture of the quadriceps tendon, rupture of the ligament of the 
patella, prepatellar bursitis, or traumatic synovitis of the knee-joint. A 
fracture of the bone is differentiated from rupture of the quadriceps 
tendon, which occasionally is torn from its attachment to the patella, 
by the absence of a sulcus above the patella and instead a sulcus in front 
of the knee where the patella is broken and the presence of downward 
mobility of the entire patella; from rupture of the ligament of the patella 
by the absence of a sulcus below the patella and possibility of upward 
mobility of the patella. Radiographic examination will clear up 
the diagnosis. 

In prepatellar dry bursitis there may at times be felt a decided crepitus 
within the bursa, but it is soft in character ; and the distended bursa 
has a localized fluctuation or elastic feel on palpation ; no swelling at the 
sides of the knee-joint is present. Traumatic synovitis may be differen- 
tiated by failure to discover two fragments of bone with a furrow be- 
tween them, by the evident floating or lifting up of an unbroken patella 
from the femur beneath it by the articular fluid, by other evidences of an 
intra-articular effusion, and by the shape of the fluctuating fluid collection. 
Radiography will aid greatly in establishing a diagnosis. 

Prognosis. — The prognosis of fracture of the patella depends upon 
the character of the fracture, the degree of separation of fragments, 
the extent of the tear of the lateral expansion of the aponeurosis, and 
the form of treatment adopted. Bony union results only when anatomical 
apposition of fragments is obtained. In transverse fractures with separa- 
tion of fragments, bony union is defeated by the want of coaptation, the 
interposition of torn edges of the aponeurosis, dropping inward between 
the fragments, and by the action of synovial fluid, which limits to a great 
extent the formation of callus. Union in cases in which there is uncor- 
rected separation of fragments is never bony but fibrous in character. 
While fairly useful function may be obtained thus if the fibrous connec- 
38 



594: TEEATISE ON FBACTUEES 

tion is close, it requires several months for its establishment, and is per- 
haps not of a character to stand much strain. Resulting stretching of 
the fibrous union may take place ; and approximation, which at first was 
fairly close, may end in a considerable separation of fragments. In trans- 
verse fracture it is only in those cases in which there is little or no tearing 
of the lateral expansion of the aponeurosis that a completely useful 
joint is likely to be obtained. In fractures by direct violence in which 
there is an oblique or comminuted line of fracture and no tearing of the 
aponeurosis and therefore no appreciable separation of fragments, bony 
union as a rule results and operative treatment is not indicated. Atrophy 
of the extensor muscles of the knee may result when the widely separated 
fragments have not been united by bone or a short fibrous connection. 
Adhesions to the femur may occur, especially in comminuted fractures or 
those in which infection has arisen, as in gunshot fractures and those 
from other direct forces. In transverse fractures with separation of 
fragments, operation and direct approximation of fragments with repair 
of aponeurotic tears should give firm bony union and good functional 
results. Before selecting the operative method of treatment the possibil- 
ity of sepsis should be made known to the patient; but he should be in- 
formed that by operation firm bony union will be obtained in the majority 
of cases with consequent shortening of the time of convalescence. The 
possibility of infection occurring in open treatment on the one hand and 
the probability of fibrous union with resulting functional impairment and 
prolonged convalescence by non-operative means on the other hand should 
be made clear to him. He should realize that the open treatment, which 
means suture of the fascia and aponeurosis and perhaps of the bone, is 
dangerous in the hands of the occasional surgeon, but practically free 
from danger when performed under a skilled modern technic. 

Treatment. — To obtain good functional results in fractures of the 
patella there must be almost anatomical apposition of fragments, which 
will give bony or a short fibrous union. This is less likely to occur under 
non-operative treatment, though it is practically possible in fractures 
with moderate laceration of the tendinous surroundings of the patella. 
A satisfactory approximation of fragments is liable to be prevented by 
intra-articular hemorrhage, contraction of the quadriceps extensor muscle, 
and interposition of torn edges of aponeurosis and periosteum. In frac- 
tures by direct violence, in which as a rule there is little or no separation 
of fragments and no interposition of aponeurosis, and in fractures by 
muscular action in which the fragments are little separated, the non- 
operative treatment is satisfying. The non-operative treatment consists 
in putting the entire extremity at rest on a posterior padded splint, with the 
knee in full extension, the leg elevated, and the thigh muscles relaxed by 
flexion at the hip-joint. This form of treatment, combined with local 
cold intermittently applied, and after the first week moderate compression 
by bandages, will give firm union, fibrous or osseofibrous, as a rule, at the 



FEACTUEES OF THE PATELLA 



595 



Pig. 693c 
Right leg. 



Fig. 693b. 
Left leg. 




Pig. 693c. — Fracture of the right patella in 1886, when 20 years old. Treated by Dr. Roberts, at Penn- 
sylvania Hospital, with Levis's separated Malgaigne hooks; shows bony union in anteroposterior and in 
lateral skiagrams. The right patella is solid, of good shape, and the mobility and usefulness of limb perfect. 
Shown at Philadelphia Academy of Surgery, March, 1916. Skiagrams taken Dec, 1920. (Lateral view.) 
Fig. 693b. — Fracture of the left patella in 1894, when 28 years old. Treated by Dr. Roberts, at Polyclinic 
Hospital, with posterior wooden splint and adhesive plaster, with limb partially flexed at hip; shows close, 
fibrous union in anteroposterior and lateral skiagrams. Patient has been a laborer ever since, goes up 
and down stairs well, has only slight restriction in forced flexion of left knee. (Lateral view.) 



Fig. 693c. 



F g. .'93J. 






Figs 693c and 693d. — Anteroposterior views of old fractures of patellas of Patrick C- 

and 693b.) 



(See Figs. 693a 



596 



TREATISE ON FBACTURES 



end of about six weeks. At the end of this time the splint may be re- 
moved, judicious passive motion and massage instituted, and at the end 
of three months active use of the leg allowed. This form of treatment 
has, however, a rather limited degree of usefulness, and should be used 
only when there is no marked separation of fragments and a competent 
operative technic is unobtainable. 

In transverse fracture of the patella with separation of fragments, 
two forms of treatment may be adopted — non-operative and operative. 
Successful non-operative treatment in the average case, as a rule, will give 
moderately close fibrous union and fair functional results after a pro- 
longed convalescence; it should be adopted only when there is some direct 




Fig. 694. — -Method of non-operative treatment of fracture of the patella on inclined p]ane. The 
leg is fixed securely by straps of adhesive plaster to the splint, and the fragments of the patella are 
approximated by two strips of adhesive plaster shown. Elevation of the leg is then made to relax the 

quadriceps extensor muscle. 

contra-indication to operation or after the possibilities of the two forms 
of treatment have been thoroughly understood by the patient. Operative 
treatment, on the other hand, should give bony union, good functional 
result, and a shorter time to obtain free use of the knee-joint. It is 
advisable when the operator is a surgeon accustomed to carrying out an 
aseptic technic and can assume with safety the treatment of possible 
septic complications. 

Non-operative Treatment (Fig. 694). — Place the foot, leg and thigh 
upon a well-padded posterior wood or wire splint with footpiece. Band- 
age the leg and thigh to the same; or use four straps of adhesive plaster 
two inches in width for that purpose applied as shown in the illustration. 
Steady the lower fragment by a strap of adhesive plaster passed obliquely 



FKACTUBES OF THE PATELLA 



597 



around the leg immediately beneath the lower fragment, elevate the 
splinted limb to flex the hip and relax the thigh muscles, place a second 
strip of adhesive plaster obliquely around the apparatus for a 
period of from four to seven weeks, changing it occasionally and giving 








Fig. 695a. — Application of the posterior ham splint in fracture of the patella to be used during 

convalescence. 

light massage to the muscles. From time to time it will be necessary, 
especially during the first two weeks, to tighten the adhesive stripping 
above and below the patella so as to maintain approximation of fragments. 
Do not flex the knee during the treatment. At the end of eight weeks 
the elevation may be discontinued and the limb brought to the extended 
position, and at the end of a few days re- 
placed by a light splint plaster dressing or 
posterior ham splint (Fig. 695a). Weight- 
bearing may be begun at about eight weeks 
while the ham splint is continued. Passive 
flexion of the knee may be started carefully at 
about ten weeks. Active motion should not 
be allowed until about the end of the third to 
the sixth month. Tt is probably wise to wear 
an elastic webbing knee bandage for a long 
time in cases where non-operative treatment 
has been adopted. Sudden strain by misstep 
may rupture the fibrous union. In some cases 
the fibrous union seems to become stretched 
by use of the limb. 

A subcutaneous peripheral suture of 
strong ligature silk, or kangaroo tendon, may 
be carried around the fragments to maintain 

apposition of the fragments. Asepsis is imperative. This minor operation 
should be done with the extensor muscle relaxed by general anaesthesia and 
the limb kept elevated. 




Fig. 695b. — Diagram of purse-string 

method of treating transverse fracture 

of patella. 



598 



TREATISE ON FRACTURES 



Operative Treatment. — Strict asepsis is absolutely necessary in opera- 
tions upon the patella. Unless one is prepared to be most exacting 
in technic, non-operative methods are advisable. Operations for repair 




Fig. 696. — Fracture of the patella. Middle dressing shows crescentic incision with edges retracted, 
transverse fracture of patella with tear of aponeurosis, and lateral expansion of the capsule. Lateral 
figures show method of repair with interrupted kangaroo tendon and chromic catgut sutures approxi- 
mating fragments and torn capsule, interrupted linear sutures in skin, and rubber tissue drains in 

both angles of the wound. 

of a broken patella should be done only in well-appointed hospitals and by 
those who are fully trained in major operative work. There is no joint 
which is more prone to infection and in which more disastrous conse- 
quences follow than the knee-joint. Infection means prolonged convales- 



FKACTUBES OF THE PATELLA 599 

cence at best, and gives rise to suppurative arthritis, subsequent ankylosis, 
suppurative myositis, failure of union, and even death. The end-result of 
suppurative knee-joints, following operation for fracture, is there- 
fore deplorable. 

An operation for patellar fracture is best performed at the end of 
from three to five days after injury, though there is no great objection 
to earlier intervention at the hand of a trained surgical expert with guaran- 
teed aseptic technic and wise after-care. A transverse semicircular incision 
with convexity upward, to keep the scar from the kneeling surface, raises 
a flap over the broken bone and uncovers the seat of fracture. The 
synovial fluid escapes and the blood-clots should be picked out with for- 
ceps. Irrigation of the joint is not advised. The torn edges of the 

Fig. 697c Fig. 6976. 





Fig. 6970. — The retaining sutures of linen inserted and the incision closed, after removing the clot 
and reuniting the torn edges of periosteum. (Wyeth.) 
Fig. 6976. — The dressing applied and the retaining stitches tied. (Wyeth.) 

aponeurosis and the periosteum covering the patella are lifted from the 
fractured surfaces, which are lightly rubbed with dry gauze to remove 
adherent blood-clot and fibrin. The fragments of the patella are brought 
together and held in approximation by a circumferential suture of No. 2 
chromic catgut, or by two interrupted sutures of No. 2 chromic catgut 
placed at the lateral edges of the patella. The lacerated aponeurosis and 
periosteum covering the patella and the torn margins of the lateral expan- 
sions of the joint capsule are sutured with interrupted or mattress sutures 
of No. 1 chromic catgut, and the skin edges with interrupted sutures of 
fine silk. The wound is closed with drainage at each angle of the wound, 
a sterile dressing is applied (Fig. 696), and the leg and thigh, on a padded 
posterior splint of wood with the hip flexed moderately, are fixed on an 
inclined plane. Massage and passive motion should begin at the end of 



600 TREATISE ON EEACTUEES 

the third week and active motion and weight-bearing at the end of three 
months. The result looked for is bony union, which generally occurs if 
anatomical approximation is maintained With proper technic infection 
is extremely rare. 

In transverse fractures Wyeth exposes the fragments by a transverse 
incision, washes out the blood clots in the joint with hot salt solution, 
stitches the overhanging connective tissue with a continuous suture of 
very fine linen thread and closes the skin with chromocized catgut. He 
then passes by means of a needle a deep transverse cord through the 
ligament of the patella and the overlying skin close to the bone. Just 
above the patella he carries another ligature deeply through skin and 



Pig. 698. — Rontgenogram one year after operation. Extreme flexion; 
function normal. (Wyeth.) 

muscle across the thigh. These have their ends sticking out of the skin at 
four points, two above and two below the broken sesamoid bone. Placing 
a pad of gauze over the seat of the fracture, he ties the respective upper 
and lower ends of the threads together. By this operation the fragments 
are held in position, separation by muscular contraction is prevented and 
the fragments do not tilt or override. Over the dressing a gypsum encase- 
ment is applied. The patient remains in bed a week with foot elevated and 
then is allowed to walk with crutches. The knotted threads are removed 
after six weeks, slight passive motion made, and the encasement readjusted. 
At the end of ten or twelve weeks the fracture is considered cured, but is 
guarded from overstrain for six months. 

Results. — W. C. Ouinby reports the results of 30 cases of 75 treated 
at the Massachusetts General Hospital, from 1898 to 1904. Six of the 
cases were treated without suture and 24 with suture, 2 of the latter hav- 
ing a double fracture. Of the 24 cases, 7 were reoperated upon for refrac- 



FRACTURES OF THE PATELLA 601 

ture and two for removal of the suturing wire. The results obtained 
were as follows : 

Unsutured, 6 Cases 

Result Per Cent. 

Perfect 3 5o.o 

Fair ". I 16.5 

Poor 2 33.5 

Serviceable knees 66.5 

Sutured, 24 Cases, 26 Operations 

Result Per Cent. 

Perfect 17 65.5 

Fair 5 190 

Poor 4 15-5 

Serviceable knees 84.5 

Perfect results included cases, having normal voluntary extension and 
flexion, 8, 18 degrees and 34 degrees, respectively, with perfect function. 
In fair results were included those having voluntary flexion to a right 
angle or a little less, with no limp or trouble in walking on the level ; 
and in poor results were those in whom flexion to a right angle was impos- 
sible, who limped or became easily tired on the level, or who required 
a cane or had to go upstairs one step at a time. While this group is rather 
small, it gives a fair idea of the two classes of treatment ; but it should 
likewise be remembered in a study of these: statistics that those cases 
selected for operation probably had wide separation of fragments and 
that the non-operated group had little separation of fragments. 

End-results. — Delatour reports the following statistics : 87 patients 
with 103 fractures; 3 cases not operated upon. Two deaths occurred, but 
neither was directly due to operation. In 99 instances the fracture was 
exposed and sutured. Six had useful joints, but. with limited motion; 
40 had flexion to, at least, a right angle, with perfectly useful joints. 
The remainder he was unable to trace. All ha'd motion to at least 45 
degrees at the time of leaving the hospital. 

Refracture of Patella. — Re fracture of a previously fractured patella 
is sometimes observed and is due to muscular pull from misstep or tum- 
bles, or it may be occasioned by a recurrence of the original form of 
injury. It is seen most frequently in recent cases of fracture, in which 
the bond of union is not strong or in which the joint structures have not 
regained their normal pliability and the muscular structures their normal 
tone. The line of refracture is, as a rule, at the original break. The 
upper fragment is torn away from the lower fragment, and on flexion 
of the knee-joint this separation is increased, while hyperextension gives 
good approximation. 

The treatment consists in immobilization of the part on a posterior 
splint, with approximation of the fragments by the adhesive plaster 
dressing and an increased convalescence with careful massage and passive 



602 



TEEATISE OX FRACTURES 



motion. Open operation and direct fixation of the fragments by suture 
of the periosteum or bone or by a circumferential suture of chromic catgut 
or kangaroo tendon may be required. 

Old Fractures of the Patella. — Old fractures of the patella with fibrous 
union may be characterized by marked separation of the fragments and 
impaired function. In such cases operation should be performed when 
the disability is great and the probability of improvement in function 
evident. Separation of fragments alone in the presence of a fairly useful 
limb is not an indication for operation. By operating on these patients, 
it may be possible to obtain union after freshening the fragments and 
approximating fragments by traction and suture. In this class alone is 
direct drilling of the fragments and the use of some form of non-absorb- 



Fig. 699a- 



Fig. 699ft- 




*f 



Fig. 699a-— Fracture of patella, untreated for six months. (See Fig. 699^.) 

Fig. 6996. — Fracture of the patella showing moderate approximation by silver wire suture. 

Good functional result obtained. (See Fig. 699a.) 



able suture, such as silver or iron wire, advisable (Figs. 69917 and 699ft) . 
When approximation of fragments cannot be obtained by traction, the 
fragments may at times be brought together by lengthening of the quadri- 
ceps extensor tendon. This may be accomplished by several lateral trans- 
verse incisions in the tendon, by tranverse incision of the fascia over the 
rectus, or by the reflection of a part of the quadriceps tendon downward, 
placing it over the two portions of the patella and attaching it to the 
ligamentum patella. Scharrz reports the transplantation of the lower 
half of a sartorius muscle to a position in front of the patellar 
fragments and suture to the latter by wire sutures, with a good functional 
result. A fracture had occurred five years previously with separation 
of the fragments at the time of operation of twelve centimetres 
(Figs, yooa-yood). 



FEACTUEES OF THE PATELLA 



603 



Rupture of Quadriceps Extensor Tendon. — Rupture of the quadri- 
ceps extensor tendon is always the result of sudden muscular action, 
usually in an effort to prevent oneself falling or making a misstep. Cases 



Fig. 



Fig. 7006. 




Figs. 700a~700d. — Examples of suture of patellar fragments in which the silver wire 
used for suture was either extruded or broken. This form of operative treatment for recent 
fractures is not advised. These illustrations are only shown to demonstrate unwise methods 

of treatment. 

have been reported in which pathologic conditions have predisposed 
to rupture. 

The rupture may take place at the junction of muscle and tendon, 
in the tendon itself, or at the point of insertion of the tendon with the 
upper edge of the patella. In the latter variety there is usually a small 
cortical fragment detached from the patella. The rupture may be com- 
plete or incomplete. 



604 TREATISE OX FRACTURES 

Symptoms. — The symptoms of complete rupture are total inability 
to extend the leg, pain, localized tenderness, the presence of a sulcus 
above the patella, and evidences of joint effusion. When the lateral ex- 
pansions of the aponeurosis are also torn, the disability is as complete 
as in similar fracture of the patella, and the other symptoms like those of 
patellar fracture without separation of fragments. 

The symptoms of incomplete rupture are localized pain, swelling, joint 
effusion, pain on extension of the leg, no distinct failure to fully extend 
leg, but that movement is done with decreased force, and there is a slight 
gap, shallow and irregular in character, above the patella. 

Prognosis. — When there is complete rupture, disability will be pro- 
longed and as a rule permanent, unless direct suture of the edges of the 
torn tendon is performed. This procedure should give a good functional 
result. In incomplete rupture good functional results are obtained by 
immobilization for four to six weeks, and direct suture is not 
always demanded. 

Treatment. — In incomplete rupture the leg and thigh should be immo- 
bilized upon a splint and the foot elevated so that flexion at the hip- joint 
is maintained. This procedure relaxes the rectus portion of quadriceps 
extensor muscle. Local compression should be applied to the knee-joint 
for one week and followed by massage of the thigh muscles. At end 
of fifth week the splint may be removed and active motions encouraged. 

In a complete rupture, incision with direct suture of the torn edges 
of the tendon is indicated. Chromic catgut or kangaroo tendon should 
be used to overlap the edges of the torn tendon with mattress stitches 
and post-operative treatment as recommended for incomplete rup- 
ture employed. 

Rupture of the Ligament of the Patella. — Rupture of the ligament 
of the patella is usually the result of muscular action, as in fracture of the 
patella and rupture of the quadriceps tendon; rarely is it the result of 
direct violence. 

Rupture may occur in the body of the ligament or at either extremity. 
When the proximal end is involved, a small cortical fragment may be torn 
from the lower edge of the patella; and when the distal end is torn, a 
small fragment of the bone is usually separated from the tuberosity of the 
tibia. The rupture is usually complete. 

Symptoms. — The symptoms of complete rupture of this ligament are 
localized pain, tenderness on pressure, inability to extend the leg, effusion 
into the knee-joint, the presence of a distinct sulcus below the patella, and 
upward displacement of the patella, which is increased by active contrac- 
tion of the quadriceps extensor muscle. At times the displacement upward 
of the patella may be from one to two inches. 

Prognosis. — Fibrous union occurs with non-operative measures, and 
there is apt to result some permanent impairment of function unless union 
be close. Some atrophy of the extensor muscle may take place and the 



FRACTURES OF THE PATELLA 



605 



patient be obliged to use a cane in walking. Operation by some form of 
suture or hooks usually gives better functional results. 

Treatment. — Non-operative measures are not recommended as a rou- 
tine. Unless there is distinct contra-indication to operation, it should 
be performed. Direct suture of periosteum or muscle, or both, with 
chromic catgut or kangaroo tendon gives excellent results. When 
the tendon is torn from the tuberosity of the tibia, direct nailing may 
be adopted. After operation the leg and thigh 
should be immobilized with, the knee extended 
and the hip- joint flexed. Massage and gentle 
passive motion may be started at the end of the \ | ^ 
fourth to fifth week or earlier, and active motion 
encouraged at the end of the eighth week. 




Fig. 701a. — Levis's separated Malgaigne's hooks, used in pairs 

for transverse fracture of patella after rubbing surfaces together 

to push periosteum from between fragments. (See Figs. 693a, 

093fr. 693c, 693d on p. 595-) 




Fig. 7016.— A pairof Levis's 

hooks applied to broken 

patella. (See Figs. 693a, 

6936, 693c, 693^.) 



Summary of Treatment of Fractures of the Patella 

Fractures with little displacement of fragments : keep limb elevated 
to relax extensor muscle by flexing hip-joint, maintain coaptation with 
adhesive plaster strips, subcutaneous purse-string, Wyeth's method or with 
Levis's modification of Malgaigne's hooks; and apply posterior splint or 
gypsum moulded splint. Fractures with great separation, open operation 
by skilled aseptic surgeon. 



CHAPTER XXIV 

FRACTURES OF THE TIBIA AND FIBULA 

Fractures at the Upper Ends of Tibia axd Fibula 

Anatomy. — The tibia (Fig. 703) is the larger and inner bone of the 
leg, and supports the weight of the body from the femur to the astragalus. 
It consists of the upper extremity, the shaft and the lower extremity. The 
upper extremity of the tibia is the largest and broadest part of the bone 
and consists of the internal and external tuberosities, which have upon 









Fig. 702. — Ossification of tibia and fibula: (A) at eighth foetal month; (B) at birth; (C) at two and one- 
half years; (D) at four years; (E) at about fifteen years, (a) Centre for shafts; (b) for upper epiphysis of 
tibia; (c) for lower epiphysis of fibula; (d) for lower epiphysis of tibia; (e) for upper epiphysis of fibula; 

(f) for tubercle of tibia. 

the upper surface the internal and external articular surfaces for articu- 
lation with the condyles of the femur. Between the two articular surfaces 
is a prominence, the intercondylar eminence or spine with two elevations, 
the internal and external. To this and into the depressions in front of 
and behind it are attached the crucial ligaments of the knee and the semi- 
lunar fibrocartilages. The intra-articular structures are of surgical im- 
portance. Anteriorly below the inf raglenoid margin there is a large rough- 
ened projection, the tubercle. 

The shaft of the tibia is three-sided, is largest at its junction with the 
upper extremity and gradually tapers until near its lower end where it 
again becomes somewhat increased in diameter. It presents an internal 
and external surface, separated from each other by the crest, and a pos- 
terior surface separated from the inner surface by the rounded inner 
border, and from the external surface by the interosseous ridge. 
606 



FRACTURES OF THE TIBIA AND FIBULA 



607 



The lower extremity of the tibia, while smaller than the upper ex- 
tremity, is larger than the shaft. Its lower surface articulates with the 
astragalus; from its lower inner side there is a process, the internal 
malleolus, having an articular external surface for the joint with the 
astragalus. The outer surface of the lower end presents a fibular notch 
for articulation with the fibula. 

The fibula (Fig. 704) is the slender bone of the leg situated external 
and nearly parallel to the tibia. It is slightly shorter than the tibia and con- 
sists of the upper extremity, the shaft, and the lower extremity. The 



Spine 
External condylar surface 



For ligamentum patellae 



External surface 



Anterior border of crest 
Interosseous border 




f^S 5 ^ Internal condylar surface 



Bursal surface 



Internal surface 



For astragalus ^ pL. i nterna l malleolus 

Fig. 703. — Right tibia, anterior view. 

upper extremity is formed by the head, the upper part forming the apex, 
and presenting a small articular facet for the tibia. The fibular head lies 
toward the back of the head of the tibia. It takes no part in the formation 
of the knee-joint. Below the head is the neck. The shaft has three 
surfaces — the internal, external and posterior, and three crests — the 
anterior, external and internal. The lower extremity presents an enlarged 
pyramidal process, the external malleolus, situated a little lower 
and posterior than the internal malleolus. It presents two facets, one 
for articulation with the tibia and the other for articulation with 
the astragalus. 



608 



TREATISE ON FRACTURES 



The tibia and fibula are connected in three ways : at the upper tibio- 
fibular articulation by the anterior and posterior superior tibio-fibular 
ligaments ; in the region of the shafts by the interosseous membrane, and 
at the lower tibio-fibular articulation by the inferior interosseous ligament 
and the anterior and posterior inferior tibio-fibular ligaments. 

The ligaments of the articulation of the femur and tibia have been 
described above. 

The ligaments about the ankle-joint in addition to those of the tibio- 
fibular joint connect the two bones of the leg with the astragalus and 



Styloid process 



Facet for tibia 
Head 



Posterior-external border 



Antero-external border 



External surface 



; — Interosseous border 



Internal surface 

Anterior surface 
Postero-internal border 



Subcutaneous surface < 



For tibia 

Articular surface for astragalus 



External malleolus 

Fig. 704. — Right fibula, anterior view. 



os calcis of the tarsus. They are the deltoid or internal lateral ligament, 
which consists of four separate ligaments — the anterior talotibial, the pos- 
terior talo-tibial, the calcaneo-tibial and the tibio-navicular ligaments ; and 
the external lateral ligament, consisting of three parts — the anterior, the 
middle and the posterior fasciculus. 

Surface Markings. — Palpation of the region of the knee-joint and 
upper part of the leg discloses the ligament of the patella in the median 
line and in the line of the tubercle of the tibia to which it is attached. The 
external and internal tuberosities may be palpated, the external being the 
more prominent of the two. Between the tuberosities of the tibia and the 



FRACTURES OF THE TIBIA AND FIBULA 609 

condyles of the femur are the two respective depressions. In either of 
these may be felt after certain traumatisms the dislocated semilunar carti- 
lage of the injured side of the joint. On the external and posterior margin 
of the leg is palpable the head of the fibula at the level of the tubercle of 
the tibia. Posteriorly is seen the popliteal space in which may be felt 
the pulsation of the popliteal artery, which is of surgical import in supra- 
condylar fractures of the femur. 

Anteriorly the prominent crest of the tibia, the shin, may be seen 
and palpated, as well as antero-internal surface of the shaft of the tibia. 
The shaft of the fibula may be only indefinitely palpated, except at its 
lower fourth, where it becomes subcutaneous. At the ankle the prominent 
bony landmarks are the external and internal malleoli, the external being 
a little lower and on a plane posterior to the internal. Normally the 
internal malleolus should be on a line drawn from the inner border of the 
patella to the inner side of the head of the first metatarsal bone. Pos- 
teriorly is seen the tendon of Achilles, which is narrowed at the level 
of the internal malleolus. At this point it is preferably cut in subcutaneous 
tenotomy, when this operation is required to prevent displacement of the 
fragments in fractures of the tibial shaft caused by spasm of the gastroc- 
nemius. Tenotomy in this region may be valuable also at times in back- 
ward rotatory displacement of the lower fragment in supracondylar 
fracture of the shaft of the femur. 

Fractures of the Upper End of the Tibia and the Fibula. — Fracture 
of the upper end of the tibia may occur as an isolated injury or may have 
an associated fracture of the upper end of the fibula. In a majority of 
instances fractures of this extremity of the tibia are not accompanied 
by fracture of the upper end of the fibula. 

Etiology. — These fractures are the result of direct or indirect force. 
Fractures by direct violence result from blows, falls, and crushing injuries 
applied to the upper part of the leg. Fractures by indirect violence result 
from lateral or anteroposterior flexion when either the thigh or the leg and 
foot is fixed. These injuries are essentially bending fractures. Forced 
abduction usually produces a fracture of the internal tuberosity, forced 
adduction, a fracture of the external tuberosity, and hyperextension an 
oblique fracture with the line of fracture running downward and forward. 
A rare form of fracture is the " compression fracture "of Wagner, due 
to a fall from a height, the patient landing on the foot and producing 
a fracture of one or both tuberosities with marked crushing of the 
tuberosities and lateral displacement of the same. Fracture by indirect 
violence as a rule involves only the tibia, although rarely there are excep- 
tions to this rule. 

Varieties (Figs. 705-727). — From a collection of 29 radiographs of 

fracture of the upper end of the tibia and fibula the following varieties 

of fracture were found: of tibial tubercle, 2; comminuted of the tibia 

and fibula, 1 ; of external tuberosity and of fibula, 1 ; of fibula alone, 2: 

39 



610 



TREATISE OX FRACTURES 

Fig. 705c Fig. 705b. 




Fig. 7050. — Tear fracture of tibial tubercle. 
Fig. 705b. — Normal epiphysis of upper end of tibia with separate centre of ossification for tibial 

tubercle. 



Fig. 706. 



Fig. 707. 




Fig. 



Fig. 706. — Tear fracture of tibial tubercle. 
-Comminuted fracture of the upper end of the tibia and fibula. 



longitudinal T-fracture of tibia with separation of both tuberosities, 4; 
compression fractures of tibia, both tuberosities, 4; lateral oblique frac- 
ture of tibia not entering joint with fracture of fibula, 3 ; lateral oblique of 
tibia not entering joint, 2; anteroposterior fracture of tibia not entering 



FBACTUKES OF THE TIBIA AND FIBULA 

Fig. 708a. Fig. 7086. 



611 




Figs. 708c and 708&. — Fracture of the external tuberosity of the tibia. Lateral and anteroposterior 

views. 



Fie 



Fig. 710. 



\ 




Fig. 709. — Fracture of external tuberosity of the tibia. 
Fig. 710. — Fracture of internal tuberosity of the tibia 



612 



TREATISE OX FRACTURES 



Fig. 711. 



Fig. 712. 





FlGS. 711 and 712. — Longitudinal T- or Y-fracture of the upper end of the tibia, with separation 
of both tuberosities. Anteroposterior and lateral views. 



Fig. 713- 



Fig. 714. 






Figs. 713 and 714. — Fracture of the upper end of the tibia (T-shaped, articular of the head) 
and of the fibula. Anteroposterior and lateral views. 



FRACTURES OF THE TIBIA AND FIBULA 



613 




\. 




61-4 



TREATISE OX FRACTURES 

Fig. 718. Fig. 719. 




Figs. 718 and 719. — Transverse anteroposterior fracture of the upper end of the tibia, and 
oblique fracture of the neck of the fibula. Anteroposterior and lateral views. 



Fig. 720. 



Fig. 721. 




Figs. 720 and 721. 



-Lateral oblique fracture of the tibia with fracture of the fibula. Antero 
posterior and lateral views. 



joint, 1; fracture of external tuberosity of tibia, 2 (large fragment); 
external tuberosity of tibia, 1 (small fragment); transverse of tibia, 1; 
transverse of tibia with fracture of fibula, 1 ; fracture of intercondylar 
eminence, 1 ; and in childhood 3 oblique fractures of tibia, not entering 



FKACTURES OF THE TIBIA AND FIBULA 

Fig. 722. Fig. 723. 

~1 r*- 



615 





Figs. 722 and 723. — Transverse fracture of the upper end of the tibia. Anteroposterior and 

lateral views. 



Fig. 724. 



Fig. 725. 




Fig. 724. — Fracture of the internal tuberosity of the tibia. 
Fig. 725. — Fracture of the intercondylar eminence. 



616 



TREATISE OX FRACTURES 



joint but involving only the diaphysis, one of these being associated 
with fracture of neck of fibula. 

Symptoms. — The symptoms of fracture of the upper end of the tibia 
vary with the variety of fracture and the size of the fragment. There is 
always localized pain, tenderness on pressure, localized swelling, and, 
when the fracture line involves the knee-joint, effusion of synovial fluid 
and blood into the knee-joint. In fractures of either tuberosity there is 
always abnormal mobility, possible passive abduction or adduction of the 
leg, and widening of the external measurements of the head; when there 
is absence of impaction of fragments, which is the rule, crepitus is present 



Fig. 726. 



Fie. 727. 




Fig. 726. — Anteroposterior oblique fracture of the upper end of the diaph/sis of the tibia. 

Fracture does not involve the epiphyseal line. 

Fig. 727. — Incomplete transverse fracture of the upper ends of the tibia and fibula. 



on motion. In T-fractures there may be marked widening between the 
tuberosities, mobility of fragments on each other, and the mobility of the 
leg in all directions from the seat of fracture. Voluntary motions of the 
leg are greatly restricted on account of pain and the lack of support. In 
compression fractures widening of the tuberosities is more marked than 
in any of the foregoing varieties, and in addition there is shortening of 
the entire leg. Displacement of fragments is due to gravity and the 
fracturing force. Palpation shows irregularity of outline, mobility, and 
displacement. Positive diagnosis as to the variety of fracture and dis- 
placement of fragments should be made by the radiogram. 

Fractures occurring in childhood may be incomplete and at times 
impacted. In the " green-stick " fracture, which is usually oblique and 
does not involve the joint, the most notable symptoms are localized pain, 



FBACTUKES OF THE TIBIA AND FIBULA. 61? 

swelling*, tenderness on pressure, angulation at the seat of fracture, 
absence of widening between the margin of the tuberosities, and absence 
of crepitus and abnormal mobility. 

Prognosis. — When good apposition of fragments is obtained, union is 
usually prompt. There is, however, a tendency toward the production 
of considerable callus, and as reduction of fragments is rarely complete, 
the normal joint surfaces are at times interfered with. There may be 
considerable diminution of function for a long time, if the line of frac- 
ture involves the joint, even when the reduction has been satisfactory. 
This is probably due to the fear on the part of the medical attendant to 
encourage early passive and even active movements of the knee-joint. 
Prior to the Great War in Europe, joints were kept immobile for too long 
a period. Continuous attention to the early and frequent institution of 
mobility in fractures near or within joints has shown better functional 
results than the practice of prolonged fixation of joints. This appears 
to be true even in gunhot fractures involving joints. 

Complications. — In comminuted fractures or in fractures attended 
by marked displacement of fragments there is the possibility of injury 
to the tibial arteries or popliteal vein, which may subsequently lead by 
gangrene to amputation. The external popliteal nerve may be injured in 
fractures involving the external tuberosity of the tibia or the head and 
neck of the fibula, and the subsequent development of callus may involve 
the nerve. This nerve lesion causes ankle-drop from motor palsy, if the 
injury to the nerve be severe. 

Treatment. — Treatment consists in reduction of fragments, which 
may be accomplished by traction, manipulation, and lateral jamming hi 
longitudinal, T-fractures, and compression fractures. In fractures of 
either tuberosity involving the joint cavity reduction may be accom- 
plished by forced abduction or adduction as the case requires. Retention 
of fragments may best be accomplished by the use of a gypsum dressing 
extending from the toes to the upper thigh. Correction of backward 
or lateral displacement of fragments is important. Permanent traction is 
not indicated, except in the compression form of fracture; then it may 
best be obtained by using a Thomas knee splint. Union occurs in from 
six to eight weeks, but weight-bearing should not be allowed for three 
months, although passive motion and massage may be given at the end 
of the third week or even earlier. Light massage and very careful passive 
motion may begin in experienced surgical hands a few days after reduc- 
tion of the fragments. 

Isolated fractures of the upper end of the tibia will not be considered 
separately, because the symptoms, diagnosis, and treatment are identical, 
whether the fracture is isolated or combined with a fracture of the upper 
end of the fibula. The only noteworthy fact in this connection is the 
relative frequency of their occurrence. In 29 fractures of the upper end 



618 



TREATISE OX FRACTURES 




FRACTURES OF THE TIBIA AND FIBULA 



619 



/ 



? 



of these bones fracture of both bones was found 8 times, isolated fracture 
of tibia 15 times, and isolated fracture of the fibula 3 times. 

Isolated Fractures of the Upper End of the Fibula. — Isolated fracture 
of the upper end of the fibula is rather rare (Figs. 728-730). In three 
cases observed the line of fracture involved the neck in two instances, and 
in the third case the line of fracture involved the upper end of the shaft 
near the neck. In all, the line of fracture was oblique in direction and was 
caused by direct violence in the form of a kick. Muscular action due to 
pull of the biceps muscle may occa- pr : 
sionally produce a fracture. 

Symptoms. — T h e symptoms 
are localized pain, tenderness, and 
possibly at times crepitus. Pain 
is often referred in the course 
of the external peroneal nerve 

(Fig. 730 • 

Treatment. — There is, as a 
rule, little if any displacement. 
The fragments are held together 
by the attachment of the muscles 
arising from this region. Immo- 
bilization on a posterior padded 
wood splint or in gypsum dressing 
for four to six weeks should give 
good results. The development 
of considerable callus may pro- 
duce pressure upon the external 
popliteal nerve, and later require 
excision of the callus. Weight- 
bearing may be begun early, be- 
cause the upper end of the fibula 
has no part in the formation of 
the knee-joint. 

Avulsion of the Tubercle of 
the Tibia (Figs. 774-776). — The 
tubercle and upper epiphysis of the tibia ossifies from a single centre, and 
unites with the diaphysis from the twenty-first to the twenty-second year. 
The tubercle at first is cartilaginous, and ossification extends downward 
from the epiphysis as a long tongue-shaped projection. 

Etiology. — The ligament of the patella extends from the tip of the 
patella to the tubercle of the tibia. Only a portion of the ligament is in- 
serted directly into the tubercle. Avulsion of this tubercle is the result of 
sudden contraction of the quadriceps extensor muscle, the pull of which is 
transmitted through the patellar ligament to its point of insertion on 
the tubercle. In very rare instances it is the result of direct violence, as 




Fig. 731. — Drawing to show the relation of the 
external peroneal nerve with the head and neck of the 
fibula. Fractures in these regions are often asso- 
ciated with severe pain due to nerve injury or 
pressure. 



620 



TREATISE OX FRACTURES 



is undoubtedly seen in cases showing distinct fragmentation of the 
tubercle. It is essentially an injury of childhood and early adult life. 

Symptoms. — There is usually a history of strain, followed by pain 
and localized tenderness in the region of the tubercle. In addition there 
is lameness and inability to fully extend the leg on account of pain; on 
palpation there may be felt thickening of the region of the tubercle or a 
movable fragment, with perhaps crepitus, which is cartilaginous in charac- 
ter. Radiographic diagnosis is possible only when there is marked separa- 
tion of the ossified portion of the tubercle in comparison with the normal 
side. It is not improbable that errors have been 
made in the correct interpretation of radiographic 
plates of this region. 

Treatment. — When there is marked separation 
or humping of the tubercle, immobilization with 
localized pressure should be used for a period of 
five to six weeks. The ultimate result of this lesion 
is good. The feasibility of operation and direct 
nailing of the displaced fragment is scarcely ever 
warranted, as the displacement has no effect upon 
the function of the patellar ligament, which is not 
entirely inserted into the tubercle of the tibia. 

Separation of the Upper Epiphysis of the Tibia 
and Fibula (Fig. 732). — Diastasis of the upper 
end of the tibia is a very unusual lesion. The 
rarity of the injury is due to the comparative small- 
ness of the epiphysis and the relation of the 
ligaments to the causative force, usually hyperex- 
tension or violent abduction or adduction of the leg. 
The ligament of the patella, the internal lateral 
ligament, and the tendon of the semimembranosus 
muscle are inserted into the diaphysis as well as the 
epiphysis. This anatomical relation probably ren- 
ders a diastasis unlikely. Slight separation 'of the 
epiphysis occurring after a sudden strain may be 
associated with fracture of the tuberosity. The 
tongue of cartilage forming the tubercle of the tibia is generally displaced 
with the epiphysis. The separation occurs in patients from three to 
twenty years of age. When there is a separate ossific centre for the 
tubercle, this may be torn off prior to the twelfth year. It is said to 
appear at the eleventh year. It is said to occur in vaulting. The usual 
lesion produced by the kind of violence which occasionally produces this 
epiphyseal separation is a diastasis of the lower epiphysis of the femur 
or an oblique fracture through the tuberosities of the tibia. 

Symptoms.— The symptoms of diastasis of the upper epiphysis of the 




Pig. 732.— Tibia, fracture of 
the head of; epiphyseal. The 
specimen consists of the adja- 
cent extremities of the femur 
and tibia of the ieft side re- 
moved from a child about ten 
years old. The separation is 
complete; the epiphysis is held 
in position by the crucial 
ligaments. (Mutter Museum, 
No. 1442.06.) 



FRACTURES OF THE TIBIA AND FIBULA 621 

tibia are displacement of the upper fragment either laterally or forward, 
causing deformity, mobility of the fragment, soft cartilaginous crepitus, 
localized pain, swelling, and joint effusion. The separation may be accom- 
panied by a wound, giving rise to an open diastasis. 

Treatment. — Reduction is accomplished by traction and manipulation. 
Immobilization is best obtained by a gypsum encasement, which should 
be split and held in place with a bandage, if there is danger of swelling. 
This should be continued for six to seven weeks and weight-bearing 
allowed at the end of twelve weeks. Lateral contour splints of metal or 
felt or gypsum gauze may be used. 

Isolated separation of the upper epiphysis of the fibula apparently has 
not been recognized. 



CHAPTER XXV 

FRACTURES OF THE SHAFTS OF TIBIA AND FIBULA 

Fractures of the bones of the leg occur in frequency next to fractures 
of the bones of the forearm. They take place at any time of life, are more 
frequent in the male sex, and in well-developed adults who lead an out- 
door life. The tibia actively supports the body; but the fibula acts in a 
supplementary manner and of itself cannot support the body weight. 
Hence it is that in fractures of the tibia by indirect force there is gener- 
ally in addition a fracture of the fibula. Fractures of both bones are most 
frequent in the middle third of the diaphysis. Plagemann's statistics show 
92 fractures of the diaphysis. Of these there were only 5 of the upper 
third, 54 of the middle third, and 33 of the lower third of the shaft. The 
line of fracture in these lesions was approximately at the same level in both 
bones 34 times; in 24 instances the line of fracture was higher in the 
fibula than in the tibia, and in 34 instances it was lower in the fibula 
than in the tibia. 

Etiology. — Fractures of both bones of the leg may be due to direct 
force, such as a kick, a blow, the weight of a falling object, or by being 
run over. They may also be the result of indirect force, as falls from a 
height, or accidents in which there is torsion or infraction of the leg with 
the foot held fast. Fractures by compression or muscular action are un- 
usual. Fractures by indirect force usually involve the lower portion of 
the middle third or the lower third of the shaft. Fractures by direct 
violence are not confined to any portion of the shaft. 

Varieties. — The line of fracture (Figs. 733-748) of the tibia may 
be transverse, oblique, V-shaped, spiral, or comminuted, and the fracture 
closed or open. Transverse fracture lines are unusual, and when seen 
are generally due to direct violence. The edges are usually serrated, and 
at times a three-cornered piece is detached from one or the other fragment. 
The usual form of fracture line is oblique, generally with the line of 
fracture running downward, forward and inward, so that the lower end 
of the upper fragment presents beneath the skin of the inner leg surface 
as a sharp fragment; at times this fragment perforates the skin. Torsion 
or spiral fractures are more common in the lower half of the shaft, are 
occasionally characterized by the separation of a triangular spiral portion 
of one of the fragments, and are often comminuted. Fractures by indirect 
violence are often open. This is due to perforation of the skin by sharp 
fragments. Fractures by direct force are occasionally open, due to either 
the fracturing force or to the development secondarily of pressure 
necrosis of the overlying soft parts. 
622 



FRACTURES OF THE SHAFTS OF TIBIA AND FIBULA 623 



Displacement of Fragments. — The tendency in fractures of the shaft 
of both bones of the leg is toward lateral and overriding displacement 
with shortening (Figs. 749-751). 
It is less frequent in the transverse 
fracture, but even there it may fre- 
quently be present. In oblique, 
spiral, comminuted, and multiple 
fractures overriding of fragments 
is the rule. The overriding, lateral, 
or anteroposterior displacement is 
due to the fracturing force, the 
weight of the body, or muscular con- 
traction. The usual displacement is 
upward, backward and outward of 
the upper end of the lower frag- 
ment. In addition there is over- 
riding, angulation at the seat of 
fracture, and outward rotation of 
the lower fragment. 

Symptoms. — The usual symp- 
toms of fracture of the shaft of 
the tibia and fibula are inability to 
use the legs so far as weight-bear- 
ing is concerned. While there may 
be cases in which the patient is said 
to have walked, it is only likely in 
incomplete fractures, or uncompli- 
cated fractures of the tibia alone. 
When both bones are broken and 
fracture is incomplete, attempts at 
lifting the leg from the bed will 
show angulation at the seat of 
fracture, varying deformity, axial 
deviation of the fragments, and 
outward rotation of the foot. Pal- 
pation along the crest of the tibia 
or its inner surface, which can 
usually be palpated beneath the thin 
overlying soft parts, will determine 
the seat of fracture of the tibia as 
well as the direction and degree of fig. 
displacement, unless such a time has 
elapsed since the accident that considerable swelling of the soft parts 
has occurred. Fracture of the fibula may also be determined by palpa- 
tion in its lower half, and by direct pressure in other regions. In addition 




733- — Spiral fractures of the shafts of the 

tibia and fibula. 



624 



TREATISE OX FEACTUBES 

Fig. 734- Fig. 735. 





FlG. 734. — Comminuted fracture of the shaft of the tibia and fracture of the 

shaft of the fibula. 

Fig. 735. — Transverse fractures of the shafts of the tibia and fibula. 



Fig. 736. 



Fig. 737. 




Fig. 736. — Oblique fracture of the shaft of the tibia with a double fracture of 

the shaft of the fibula. 

Fig. 737. — -Oblique fractures of the shafts of the tibia and fibula; considerable 

overriding of the fragments. 



FKACTUKES OF THE SHAFTS OF TIBIA AND FIBULA 625 

Fig. 73S. Fig. 739 




Fig. 738. — Spiral fracture of the shaft (low) of the tibia with spiral fracture of 

the shaft (high) of the fibula. 

Fig. 739. — -Double spiral fracture of the shaft of the tibia. 



Fig. 740. 




Fig. 741. 




Fig. 740. — Double spiral fracture of the shaft of the tibia. (Another view of 

Fig. 739.) 
Fig. 741.— Spiral fracture of the shaft of the tibia. 



40 



626 



TREATISE OX FRACTURES 

Fig. 742. Fig. 743- 




Fig. 742. — Double spiral fracture of the shaft of the tibia. 
Fig. 743. — Old healed fracture of the shaft of the tibia and recent fracture of the shaft of 

the fibula. 



Fig. 744- 



Fig. 745- 








Fig. 744. 



-Oblique fracture of the shafts of the tibia and fibula. Union has occurred with 
lateral displacement and overriding. 
Fig. 745. — Incomplete fracture of the shaft of the tibia in a boy aged 12 years. Antero- 
posterior view. (See Fig. 746.) 



FRACTURES OF THE SHAFTS OF TIBIA AND FIBULA 627 



to these symptoms there will be localized tenderness, pain, swelling of the 
soft parts, crepitus, preternatural mobility (Fig. 752) and shortening. 
The shortening may be determined by measuring from the upper edge of 
the inner tuberosity of the tibia to the tip of the internal malleolus (Fig. 
753), and by comparison with uninjured leg. Late symptoms are the 
formation of blebs, ecchymosis, cellulitis, and cedema. The recognition 
of crepitus may be prevented by interposition of soft parts or impaction 
of fragments. In doubtful cases rontgenograms should be taken in antero- 
posterior and lateral planes to determine accurately the seat and variety 
of fracture and the degree of displacement of fragments. 



Fig. 746. 



Fig. 747. 



Fig. 748. 





: _ • _ _ _ . J 

Fig, 746. — Incomplete fracture of the shaft of the tibia in a boy aged 12 years. Lateral View. (See 

Fig. 745.) 
Figs. 747 and 748. — Oblique fracture of the shaft of the tibia; boy aged 5 years. Anteroposterior and 

lateral views. 

Complications.— The complications seen in closed fractures of the 
tibia and fibula are injury to the anterior or posterior tibial or peroneal 
arteries, or the nutrient artery of the tibia, and rarely injury to the peroneal 
or tibial nerves. The complications of open fractures are sepsis, cellulitis, 
necrosis of fragments, and pressure necrosis of the overlying soft parts. 

Prognosis. — Union occurs in closed fractures of the tibia in from 
five to eight weeks and in the fibula in from four to six weeks. It depends 
in great measure upon the accuracy of reduction. Persistent displacement 
of fragments will delay union, and permanent interposition of soft parts 
may result in pseudarthrosis. The usual fracture of bones of the leg 
treated by non-operative means results in satisfactory union without 
special deformity or disability if the surgeon has mechanical acumen, 
anatomical knowledge and surgical experience, and gives attention to his 



628 



TREATISE OX FRACTURES 



patient. Displacement of fragments, prominence particularly of the 
lower end of the upper fragment, shortening, axial deviation, and pos- 
terior angulation at the seat of fracture may readily occur under other 
circumstances (Fig. 754 ) In comminuted fractures there may be ex- 



PlG. 749- 



Fig. 750. 




Fig. 751. 



i 



— E 



FlG. 749- — Tibia and fibula (left). Fracture of both bones below middle. Firm union with consider- 
able displacement. The lines of fracture were oblique in both cases, passing from the crest in front 
downward and backward. There is a decided concavity anteriorly with considerable shortening. 

(Mutter Museum, No. 1427.67.) 
Fig. 750. — Tibia and fibula (right). Fracture of both bones. Union. The plane of fracture 
starts in the fibular side of the tibia from a point 13 cm. above the ankle-joint, passes downward to 
a point on the inner side 6 cm. from the malleolus. In the fibula the plane passes from a point in 
the anterior surface 4 cm. below the styloid process to a point in the posterior surface 10 cm. below 

that process. (Mutter Museum, No. 1427.55.) 
Fig. 751- — Drawing to show the characteristic displacement of fragments in oblique fractures of the 
shaft of the tibia and fibula. (.4) quadriceps muscle; (B) femur; (C) patella; (D) tibia; (E) fibula. 

cessive callus formation, shortening, and persistent local pain accentuated 
by weather changes. The presence of some stiffness of the knee- and 
ankle-joints prolongs the time of convalescence, and is usually due to 
prolonged immobilization without massage and early mobility of these 
joints. In open fractures there is the possibility of suppuration develop- 
ing here as elsewhere, unless sterilization of the wound is primarily effec- 



FKACTUKES OF THE SHAFTS OF TIBIA AND FIBULA 629 

tive If it occurs, union is delayed, there may be necrosis of fragments, 
sinuses persistent for months, and the ultimate result a shortened leg 
with some degree of angular deformity, oedema of the soft parts, infiltra- 
tion of the muscles, with atrophy and stiffness of the ankle-joint. These 
results are unusual in the hands of well-equipped surgeons who have had 
a chance to treat the case from its beginning, and have taken advantage 




V 

mKm ^ 

Fig. 752. — Method of determining abnormal mobility and crepitus in fracture of the shafts of the 

tibia and fibula. 

of their opportunities. Delayed union often persists for a long time. 
Non-union is occasionally seen. A true pseudarthrosis is sometimes 
developed in septic cases. 

Treatment. — The treatment to be adopted in fractures of the shaft 
depends upon the variety of fracture and possibility of obtaining anatomi- 
cal apposition of fragments. In many fractures reduction should be 
promptly performed under general anaesthesia. Some delay may be 
warranted if shock be present to a marked degree. Reduction in closed 




B- 



\ 



Fig. 753. — Method of measurement from the internal tuberosity to the internal malleolus of the tibia 

to determine shortening. 

fractures usually may be accomplished readily by strong, steady traction 
on the foot, countertraction at the flexed knee, and local manipulation of 
the fractured ends. Interposition of soft parts can generally be removed 
by this method, and anatomical coaptation of the fragments obtained. 
Usually there is comparatively little difficulty in maintaining- this anatomi- 
cal position. In transverse fractures and in a few oblique fractures it is 
possible to interlock the fragments into* approximately their normal posi- 
tion. Other cases may show overriding of fragments when traction and 
countertraction are stopped. 



630 



TREATISE OX FEACTUEES 



In the majority of cases it is comparatively easy to devise a suitable 
apparatus to maintain the fragments in their normal position without pro- 
ducing undue pressure from traction about the ankle. It is in these unusual 
cases that operation and direct fixation of the fragments by means of 
a bone inlay or a metal plate are advised. If the non-operative form of 
treatment is used, the careless or inexperienced doctor may expect a 
certain degree of shortening, overriding, and angulation of fragments, 
perhaps with axial deviation. In the operative treatment there is a possi- 
bility of mild sepsis delaying union and cure and necessitating removal 
of the fixation plate, or of severe sepsis leading to amputation or death. 
Neither form of treatment is likely to be difficult in skilled hands. 

Non-operative Treatment. — The foot and leg should be cleaned with 




Fig. 754. — Drawing to show how shortening may take place by posterior angulation (middle figure) of 
fragments, and by overriding of fragments (right-hand figure) (left-hand figure is normal for comparison). 

(Modified after Zuppinger.) 

water and soap and alcohol, and after reduction should be temporarily 
immobilized in a pillow and side splints extending from the mid-thigh 
to below the foot. When maximum swelling has taken place this dressing 
should be removed, further attempts at reduction made, if deformity still 
exists, and the foot, leg and thigh immobilized in a gypsum case, which 
should be split down the front or on each side. When using a gypsum 
case, one should be careful to preserve the normal line of foot and leg; 
there should be no anteroposterior or lateral angulation at the seat of 
fracture. The foot should be at right angle to the leg without eversion, 
and the knee-joint included in the gypsum dressing. The case is split down 
both sides, forming an anterior and a posterior portion, or in front, so 
that the case may be removed from time to time, the seat of fracture 
inspected, angulation corrected, and frictions, massage, and passive 
motions used. At the end of three or five weeks in average cases a new 



FKACTUBES OF THE SHAFTS OF TIBIA AND FIBULA 631 

gypsum case may be applied and the patient allowed up on crutches. 
Weight-bearing may be encouraged at the end of eight weeks, except in 
oblique or spiral or otherwise troublesome fractures. By raising the well 
foot with a thick-sole shoe, the patient may go about on crutches very 
early in leg fractures. Early union is probably hastened by early de- 
pendent leg and exercise in open air on one's crutches. 

A swinging fracture-box (Fig. 755) for ten days or two weeks, with 
frequent inspection, massage and mobility, followed by a gypsum case, 
may be used. This method is very often a preferable one. By fastening 




9 

Fig. 755. — 'Method of treating fractures of both bones of the leg in a swinging fracture-box. The 
flexion of the knee may be altered without disturbing the fracture and the degree of elevation 
changed when necessary by modifying the attachments between box and pulley. The patient can 
readily alter his position in bed and thus avoid bedsores over sacrum. The bed-pan is easily 
placed under the buttocks. The box should be opened daily for the first week and the leg examined, 
bathed and rearranged in the box after slight passive and active mobility of joints and gentle massage. 



a rope and weight to the footboard of the fracture-box and having the 
box to slide on a smooth wooden surface placed on the bed, traction may 
be added in rebellious fractures. The fracture-box in this traction method 
of dressing leg fractures should not be suspended. Tenotomy of the 
tendon of the calf muscles at the heel will often relieve displacement caused 
by gastrocnemius spasm. In ordinary cases the flexion of the knee by 
swinging the box splint relaxes this muscle enough. 

When there is a marked tendency to recurrence of deformity after 



632 



TREATISE ON FRACTURES 



attempts at reduction and operative measures are contra-indicated, trac- 
tion upon the lower fragment may be made with the hip and knee flexed, 
using the modified Zuppinger apparatus (Fig. 756). When there is no 




Fig. 756a. — The modified Zuppinger traction apparatus for treating fractures of both bones of the leg. 




Figs. 7566 and 756c — Cabot posterior wire splint used in tT 

unattended by deformit; 



bones of the leg 



tendency to displacement of fragments, a convenient form of dressing 
is the Cabot posterior and side splints. 

Operative Treatment (Figs. 757-770). — When it is found impossible 
to maintain anatomical apposition of fragments as proved by inspection 



FRACTURES OF THE SHAFTS OF TIBIA AND FIBULA 633 




634 



TREATISE OX FRACTURES 



/ 




\ 








FBACTUBES OF THE SHAFTS OF TIBIA AND FIBULA 635 



and confirmed by radiograph, which is unusual, and there are no contra- 
indications to operation, it is proper to operate and retain the fragments 
in their normal position by a bone inlay or by a metal plate. This is 
seldom necessary in the usual fractures. Care should be taken after the 
application of the plate to continue traction and prevent angulation at the 
seat of fracture until the wound is closed, and a sterile dressing and gyp- 
sum case applied. In operative cases treated by metallic fixation the time 
for union is a little longer than when the fragments are correctly apposed 
and treated without operation for direct fixation. The after-treatment 
is the same as that given under non-operative treatment. The plate is to 
be buried under the muscles on the outer side of the shaft, according to 



Fig. 765. 



Pig. 766. 




Figs. 765 and 766. — Photographs showing result obtained in fracture of shafts of tibia and 
fibula. (See Figs. 761 to 764.) 

Lane's technic, who leaves it indefinitely in the tissues. It would seem 
likely that a superficial plate on the subcutaneous surface of the bone would 
answer as well for fixation, and always be easily removed by incision 
after its usefulness had ended. 

Open Fractures. — In infected open fractures, the principal objects are 
to control hemorrhage and primarily to render the wound aseptic, for 
the details of which treatment the reader should consult the paragraphs 
on treatment of open fractures, contaminated and infected, and gun- 
shot fractures. 

Infected open fractures may be treated on a posterior Cabot or wooden 
splint with footpiece, or by using side splints or a divided gypsum case 
extending above and below the seat of fracture. 



636 



TREATISE OX FRACTURES 



Fig. 767. 



Fig. 768. 





Figs. 767 and 768. — Transverse fracture of the tibia with incomplete fracture of the 
fibula. Baseball player injured sliding into second base. Failure of reduction of frag- 
ments by non-operative measures. (See Figs. 769 and 770.) 



Fig. 769. 



Fig. 770. 





Figs. 769 and 770. — Transverse fracture of the tibia and incomplete fracture of the 

fibula. Reduction by operative means and fixation of tibial fragments by steel plate. 

(See Figs. 767 and 768.) (Courtesy of Dr. J. M. Spellissy.) 

It is, in the opinion of one of the authors, proper to treat infected 
open fractures by the fracture-box and gypsum splint, as are closed frac- 
tures. The primary care of the wound if successful will permit it to 
heal rapidly and the fracture-box may then be superseded by the gypsum 
encasement. If the wound suppurates the fracture-box may be used 



FBACTUBES OF THE SHAFTS OF TIBIA AND FIBULA 637 

for a longer period and the gypsum case, which is then substituted, may 
have an opening- like a window cut in for inspection and dressing of the 
wound. Drainage is important in bad infections. 

The report of the Committee on Fractures of the British Medical 
Association shows that in closed fractures of both bones the percentage 
of good anatomical and functional results by non-operative means was 
44.4 and by operative means 63.6; that good functional results with poor 




Fig. 771. — Photograph showing a result often obtained in badly commi- 
nuted open fractures of the bones of the leg followed by suppuration. 

anatomical results were obtained in 70 per cent, by non-operative means 
and 68.1 per cent, by operative measures, while in fractures of the tibia 
alone the percentage was, respectively, 74.4 and 76.4. The improvement 
in treatment of isolated tibial fractures is due in a great measure to the 
intact fibula acting as a splint for the tibia. 

The poor results found in the non-operative treatment by this Com- 
mittee is believed by Roberts to be largely due to prolonged immobiliza- 
tion, infrequent inspection, and negligence of early mild massage and 
mobility, so frequent in British surgery until Lane's propaganda for 



638 



TREATISE OX FRACTURES 




FBACTUBES OF THE SHAFTS OF TIBIA AND FIBULA 639 

operative treatment caused scientific non-operative treatment to be more 
usual. The Reports of the Committee of the American Surgical Associa- 
tion for 1913-14-15, and later, will be found of interest in this connection. 

Isolated Fractures of the Shaft of the Tibia. — Plagemann's Rostock 
statistics based on 1393 fractures show isolated fractures of the shaft 
of the tibia in 24 cases (1.79 per cent.) and of the fibula 30 cases 
(2.15 per cent.). 

Isolated fractures of the shaft of the tibia are rare (Figs. 772-775). 



Fig. 776. 



Fig. 777- 





Fig. 776. — Comminuted fracture of the shaft of the fibula. Direct violence. 
Fig. 777- — Oblique fracture of the shaft of the fibula. 

When the tibia is broken by direct violence the fibula may escape injury, 
but often it is also broken ; when the fracture of the tibia is due to indirect 
violence, the weak fibula is unable to sustain the weight of the body thrown 
upon it and is also fractured. 

Symptoms. — The symptoms of isolated fracture of the tibia are 
similar to those of fracture of both bones of the leg, but have certain modi- 
fications. The patient may be able to bear some weight on the leg if the 
fracture line is transverse and the fragments interlocked. There is only 
moderate mobility of fragments, slight overriding, crepitus, localized 



640 TEEATISE OX FRACTURES 

pain, tenderness and swelling but not so much deformity, and axial rota- 
tion of the lower fragment. The sound fibula tends to act as a splint for 
the fractured tibia. 

Treatment. — As there is not such a tendency to overriding and de- 
formity as is seen when both bones are broken, ordinary non-operative 
measures will more often give a good anatomical and functional result. 
The treatment is the same as given above for fracture of both bones. 
Weight-bearing in walking need not be postponed so long as in fracture 
of both bones of the leg. In spiral and oblique fractures in this region, 
it may occasionally be found necessary to operate and directly fix 
the fragments. 

Isolated Fracture of the Shaft of the Fibula (Figs. 776 and 777). — 
This injury is generally caused by direct violence except in the lower third 
of the shaft. 

Symptoms. — There is little if any tendency toward displacement of 
fragments on account of the firm attachment of muscular structures and 
interosseous membrane. Overriding, axial displacement, and angulation 
are extremely rare. There may at times be some lateral displacement 
inward of the upper end of the lower fragment. The chief symptoms 
are localized tenderness, pain on direct pressure, and on forcing the shaft 
of the two bones together crepitus may be demonstrated. Locally there 
is generally some bruising of the soft parts, swelling, and later ecchy- 
mosis. Walking is often possible, but generally attended by consider- 
able pain. 

Treatment. — If there is little displacement of fragments, all indica- 
tions for treatment are met by immobilization in a gypsum splint extend- 
ing from the toes to just below or a little above the knee. This dressing- 
should be used for from three to five weeks and be followed by a bandage. 
Weight-bearing may be begun at the fifth to sixth week. If there are 
complications such as nerve injury or marked displacement, it may be 
wise to cut down upon the bone to relieve the pain or readjust and hold 
fragments in position by suture of catgut. 



CHAPTER XXVI 

FRACTURES OF THE LOWER ENDS OF TIBIA AND FIBULA 

Supramalleolar Fractures (Figs. 778-783). — This class includes 
all breaks occurring within a half to two inches of the lower end of the 
tibia. Many of them are extra-articular, while a fair proportion involve 
the tibiotarsal joint. Comminution of fragments is fairly constant. 

Statistics.— Plagemann's statistics show 22 cases of fracture. In 13 
instances the fractures were extra-articular; and of these the fracture line 
was transverse 6 times, oblique in 2 cases, spiral 3 times, and in 2 cases 
there was a transverse fracture with a breaking off of a three-cornered 
piece of bone. In 7 cases the line of fracture extended into the ankle-joint, 
and of these 4 were classified as T- or Y-fractures and 3 as severe com- 
minuted fractures; in 2 cases there was found a transverse fracture of 
the internal malleolus. The fibula was 1 1 times fractured approximately 
at the same level, 8 times in the external malleolus; twice there was a 
double fracture of the fibula, in one case involving the lower third of the 
shaft and external malleolus, and in the other the neck of the fibula and 
the external malleolus. 

Etiology. — These fractures may be the result of direct violence, as in 
severe blows above the ankle, and run-over accidents, but as a rule they 
result from indirect force, as in falls from a height, with the patient land- 
ing on his foot in an inverted or everted position. The result is a frac- 
ture, above the malleoli, transverse, oblique, spiral, or longitudinal in 
character. An accompanying fracture of the fibula is usually present. 

Symptoms. — In fractures not involving the joint the symptoms are 
more or less similar to those of fracture of both bones in the lower third 
of the shaft. Usually there is marked swelling of the entire lower leg, 
pain, ecchymosis, deformity, undue mobility, lateral or posterior displace- 
ment of the foot and lower fragment, crepitus, and inability to bear weight 
on the foot. In fractures involving the joint there is, in addition, widen- 
ing of the ankle-joint, and there may be displacement upward of the 
astragalus between the fragments into the interosseous space. 

Diagnosis. — The condition should be carefully differentiated from 
dislocation of the foot, fracture of lower third of shaft, and fracture of 
the lower part of the fibula with posterior dislocation of the foot. 

Prognosis. — The prognosis for a good result without deformity and 
without restriction of the motion at the ankle-joint is particularly grave 
when the fracture is comminuted or involves the ankle-joint. Even in 
cases which do not involve the ankle-joint, impairment of motion and 
deformity are frequent; but this defect may usually be averted by careful 
41 641 



642 TREATISE OX FRACTURES 

attention to reduction and sufficient solicitude about maintaining the integ- 
rity of the soft tissues by massage and early mobility. 

Treatment. — Treatment consists in reduction of fragments by traction 
and manipulation, immobilization for one week or more in pillow and 
side splints or a swinging fracture-box, and later in a gypsum case. Care 
should be taken to secure as nearly normal apposition of fragments as is 
possible and to< correct all external deformity. Immobilization should be 
continued for at least six to eight weeks, but at the end of two or three 
weeks or earlier careful massage and passive motion may be given. 
Weight-bearing may begin about the end of the tenth or fifteenth week, 

Fig. 778. Fig. 779. 





Fig. 778. — Supramalleolar fractures of the tibia and fibula. 
Fig. 779. — Supramalleolar fracture of the tibia. 

varying with the line of fracture and the weight and work of the patient. 
A high sole on uninjured side with crutches a few weeks longer is better 
surgery than hasty ambulation with resulting bending at the seat of break. 
It was the bad mechanical results in these fractures that caused Lane to 
examine London policemen and other constant walkers, who had sus- 
tained ankle fractures. He found bad final results with grave disabilities. 
In many the axis of the limb was permanently altered with resultant change 
in the bearing of the articular planes on each other. Even after unassisted 
walking is allowed a high-laced shoe or boot is a desirable support to the 
ankle for some months. This offers protection against sudden misstep. 
Separation and Fracture of the Lower Epiphysis (Figs. 784-786). — 
Complete separation of the lower epiphysis of either the tibia or the 
fibula is an extremely rare injury. The lesion which is most frequently 



FRACTURES OF THE LOWER EXDS OF TIBIA AND FIBULA 643 






644 



TREATISE ON FRACTURES 



observed is not a complete separation, but a fracture through the tibial 
epiphysis with a tearing off of a small portion of the diaphysis. The line 
of fracture through the diaphysis is a high fracture through the internal 
malleolus and through the internal and anterior portion of the diaphysis. 
These injuries are observed before the twentieth year. 

Etiology. — The cause of these fractures is either marked forcible 
eversion or inversion of the foot, as in jumping or in falls from a height. 

Symptoms. — Displacement of fragments 
is usually very slight. The usual symptoms 
are those of an acute synovitis of the ankle- 
joint, or a sprain, and in addition localized pain 
on motion, tenderness on pressure over the 
epiphyseal line, and at times cartilaginous 
crepitus. 

Treatment. — In the absence of displace- 
ment of fragments the treatment consists in 
immobilization in a gypsum case for four or 
five weeks, after which time the patient 
may be allowed to use the leg cautiously 
with the ankle region supported by adhesive 
plaster strapping. 

Malleolar Fractures 

Fracture by Eversion and Abduction. — 

The term Pott's fracture is erroneously given 
by the majority of physicians to all fractures 
occurring about the ankle-joint. This is a 
mistake. The lesion described by Percival 
Pott is a fracture of the fibula not higher than 
two to two and a quarter inches above the tip 
of the external malleolus, which is the weakest 
point of the fibula and just above the tibio- 
fibular ligament, with a rupture of the internal 
lateral ligament accompanied by outward dis- 
location of the foot. The term as now used 
includes cases in which there is a tear- or 
strain- fracture of the internal malleolus in- 
stead of a mere rupture of the internal lateral ligament. The name Pott's 
fracture should be dropped and the descriptive anatomical term employed. 
Etiology. — Indirect violence is the cause of the majority of these frac- 
tures. The injury is the result of a combination of factors— usually ever- 
sion of the foot, rotation about its long axis, and abduction from the 
vertical axis of the leg. It is liable to occur when the foot is firmly held, 
and the body forced outward by violent rotation of the leg when the foot 
is fixed, and by falls upon the foot when it is everted or abducted. 




Fig. 783- — Supramalleolar fracture 
of tibia and fibula. Oblique fracture 
occurred in the tibia starting on the 
fibular side 9 cm. from the ankle- 
joint and passing downward and 
inward to a point 3.5 cm. above the 
apex. (Mutter Museum, No. 1427.81.) 



FRACTURES OF THE LOWER ENDS OF TIBIA AND FIBULA 645 





FlG. 784. — Fracture of internal malleolar portion of lower epiphysis of the tibia. Antero- 
posterior and lateral views. 




Fig. 785. — Separation of the lower tibial epiphysis with fracture of the fibula. Anteroposterior 

and lateral views. 



646 



TREATISE OX FRACTURES 




FRACTURES OF THE LOWER ENDS OF TIBIA AND FIBULA G47 



Mechanism of Fractures. — The 
mechanism of the fracture is explained 
as the resultant of two forces — pressure 
and traction (Figs. 787 and 788). In 
falls outward with the foot fixed, ever- 
sion and abduction of the foot are pro- 
duced, the internal lateral ligament is 
stretched, and, as it rarely ruptures, the 
force tears off the internal malleolus, 
generally at its base; as the force con- 
tinues the astragalus is forced against 
the external malleolus, fixing the latter ; 
at the same time the weight of the body 
falling outward carries with it the leg 
and the fibula ; the fibula is checked by 
the astragalus and kept attached to the 
tibia by the tibiofibular ligament ; either 
the latter ruptures or a line of fracture 
occurs at the weakest point of the fibula 
just above the point of attachment of 
the tibiofibular ligament. It is here that 
the fixed portion of the fibula meets the 
potential moving upper portion, and 
fracture occurs about two to two and 
a quarter inches above the malleolus. 




Fig. 787. — Drawing to show the normal struc- 
tures of the ankle-joint: (a) Tibia; (b) astragalus; 
(c) internal lateral ligaments; (d) interosseous 
ligajrnent; (e) calcaneum; (/) fibula; (g) posterior 
fasciculus; (h) middle fasciculus of external 
ligament; and (i) interosseous or tibiofibular 
ligament. 




Fig. 788.— Drawing to show the most common types of fracture about the ankle-joint, made after 
rontgenograms (Figs. 789- 790, and 802) and methods of reduction of these types of fractures. (A) Frac- 
ture of fibula with rupture of the internal lateral and tibiofibular ligaments; (B) fracture of the fibula 
with fracture of the internal malleolus, and (C) fracture of the external and internal malleolus. (.4 
and B) are types of the classic Pott's fracture by eversion and abduction of the foot, and (C) is of the 
reversed Pott's fracture by inversion and adduction of the foot. The arrow in each figure shows the direc- 
tion of force necessary to reduce these fractures. 



648 



TREATISE ON FRACTURES 





The line of fracture of the fibula depends to a great extent upon whether 
the fall is directly outward or whether some torsion of the tibiotarsal 

joint occurs at the moment of frac- 
ture. Another result of this mechan- 
ism may be fracture of the internal 
malleolus, as above described, with 
fracture of the external malleolus 
just above the level of the tibiotarsal 
joint by outward pressure of the 
astragalus. 

Displacement (Figs. 789-793). 
— In typical cases the line of fracture 
of the fibula is oblique or spiral in 
character and is situated within the 
lower two and a quarter inches of 
w. Surface tne l° wer en< 3 of that bone. The foot 

fig. 7 8 9 .-Fracture of tibia into ankle-joint not is usually rotated outward and later 

recognizable by palpation of malleolar surface of ^U r ] ur f^A WVipn tViic r1icr^1a^m^-n+- 

tibia. Displacement resembles that of dislocation ^DClUCiea. VV lien tlllS displacement 

backward at ankle. takeg place thg upper end Q f ^ j ower 

fragment is displaced inward and the external malleolus outward ; when 
there is considerable tearing across the anterior capsule of the joint, 
there is generally posterior disloca- 
tion of the entire foot with accom- 
panying displacement of the fibular 
fragment. When there is, in addi- 
tion, fracture of the tibial malleolus 
instead of simple tearing of the in- 
ternal lateral ligament, the line of 
break is generally transverse across 
the base of the malleolus and the 
separated fragment is displaced out- 
ward with the astragalus, and pos- 
teriorly if the latter is so displaced. 
There occurs a variety of this frac- 
ture in which the fibula is broken 
above or through its malleolus and 
the tibia fracture by a line running 
obliquely upward and outward from 
the articular surface of the lower end 
of the tibia. In this injury the break 
of the tibia is perhaps often over- 
looked. It is liable to permit marked fig 
displacement of the foot backward, 
and may be mistaken for a backward luxation of the tarsus at the astragalo- 
tibial joint. Roberts has occasionally seen this type of fracture since 




^1 



■ n 



/ 



/ 



j 

790. — Fracture of fibula with rupture of in- 
ternal lateral and tibiofibular ligaments. 



FRACTURES OF THE LOWER ENDS OF TIBIA AND FIBULA 649 






A B 

Fig. 791. — Fracture of the fibula with fracture of the internal malleolus: anteroposterior and lateral 




** 





A B 

Fig. 792. — Fracture of the fibula (low) with fracture of the internal malleolus; antero- 
posterior and lateral views. 



650 



TREATISE OX FKACTUKES 



his earliest years of practice; but has never verified his belief by X-ray 
examination. He first saw cases before X-rays were known. 

Symptoms. — All of these cases are not characterized by deformity 
when seen by the surgeon, for in many the deformity has been reduced by 
a friend pulling upon the foot. The most notable symptoms are general- 
ized swelling about the ankle, localized on the inner side about the tip of 
the internal malleolus and on the outer side localized not at the tip of the 
fibular malleolus but somewhat above the malleolus. There is localized 
pain which is increased on attempts at walking. Palpation reveals tender- 
ness on pressure and crepitus about two inches above the tip of the external 





A B 

Fig. 793- — Fracture of the fibula with fracture of the internal malleolus. Marked posterior 
displacement of the foot. Anteroposterior and lateral views. 

malleolus (Fig. 794) with moderate angulation of fragments; and over 
the internal malleolus there may be felt the sharp edge of the tibia from 
which the internal malleolus has been torn. This is particularly noticeable 
if external lateral displacement of the foot is made. Crepitus may also 
at times be detected over the internal malleolus. When the lesion is a mere 
rupture of internal lateral ligament and not a fracture of the internal mal- 
leolus, no crepitus is discoverable in this region. By grasping the leg with 
one hand and the foot with the other, abnormal lateral mobility of the foot 
in the mortise of the ankle-joint may be obtained in some cases (Fig. 795). 
When there is displacement of the foot, it will be noticed that the foot 
is slightly abducted and everted in the valgus position. A line drawn 
through the long axis of the tibia normally is prolonged between the first 
and second toes ; but in the event of this displacement of the foot, it falls 



FRACTURES OF THE LOWER ENDS OF TIBIA AND FIBULA 651 



to the inner side of the foot. There is also prominence of the upper frag- 
ment of the tibia at the region of the internal malleolus and apparent broad- 
ening of the ankle-joint. On the outer side of the ankle-joint there is 
angular deformity corresponding to the fracture of the fibula. 

If there has occurred marked laceration of the anterior and posterior 
portions of the joint capsule, a posterior as well as an outward displace- 

FiG. 794- 




Fig. 794. — Method of determining crepitus in fracture of the lower end of the fibula by 
rocking of the lower fragment. 

Fig. 795- 




FiG. 795. — Method of determining lateral mobility of the ankle-joint in fractures of the 

malleoli. 

ment of the foot may be present. This may be determined by comparison 
of the lateral aspects of the injured leg and foot with the sound side by 
palpation. It will be noticed that the lower articular edge of the tibia may 
be felt at the ankle, and by grasping the foot and leg with the two hands it is 
possible to demonstrate the dislocation by pulling the foot forward on the 
leg. In all cases radiograms should be made in anteroposterior and lateral 
planes not only to determine the variety of fracture, but also the amount of 
displacement of fragments. The supramalleolar fracture of the fibula with 



652 



TREATISE ON FRACTURES 



fracture of the lower end of the tibia, without its line involving the tibial 
malleolus at all, but running into the astragalotibial joint, has been called 
by some the drunkard's fracture. It permits marked eversion and posterior 
displacement of the foot, and is differentiated from luxation by crepitus 
and the easy reproduction of the deformity after reduction under ether. 
Roberts's attention was called to it by his surgical preceptor in the early 
seventies of the nineteenth century. 

Prognosis. — The prognosis of Pott's fracture of the fibula depends 




Fig. 796. — Method of reduction of classic Pott's fracture by forced inversion of the foot and 
correction of posterior displacement if it is present. 




Fig. 797. — Application of a pillow and side splints for temporary immobilization of fragments 

before placing the foot and leg in a gypsum case. This form of immobilization should be used 

until the maximum swelling begins to disappear. 

upon the accuracy of replacement of fragments, the maintenance of nor- 
mally apposed joint surfaces, and the original severity of the lesion. Frac- 
tures of the internal malleolus with supramalleolar fracture of the fibula 
should give good results, if the fragments are returned to their relations 
and held so until union is firm. Even when there is considerable laceration 
of the joint capsule or of the internal lateral and tibiofibular ligaments, the 
prognosis for weight-bearing should be good, but function may be more or 
less permanently impaired. When there is persistent eversion of the foot, 
permanent disability results from the weight of the body being carried on 



FRACTURES OF THE LOWER ENDS OF TIBIA AND FIBULA 653 

the foot out of proper line. This produces a strain upon muscles, liga- 
ments, and joint surfaces, so that there is lameness and increased tendency 
to deviation from the normal axis, and a permanent valgus position ensues. 
It is very liable to occur when the nature of the lesion has been misunder- 
stood in the injury called " drunkard's fracture " of the tibia and fibula. 

Treatment. — To obtain good functional results in the different varie- 
ties of fracture of tibia and fibula at the ankle, there must be accurate 
reduction of fragments and a corrected position o>f the foot with efficient 
control of its anatomical relations until union takes place. In all but the 
cases with little or no displacement, reduction should be performed imme- 
diately after the diagnosis is made, and is best obtained with the aid of 
general anaesthesia. There are three movements necessary in making per- 
fect reduction : The foot must be carried forward to overcome posterior 
dislocation, and inward in order to bring the base of the tip of the internal 
malleolus to its proper site on the tibia and to correct outward displace- 
ment of the astragalus and that of the lower fragment of the fibula; and 
slight inversion made to relax the tension of the internal lateral ligament 
on the internal malleolus and to prevent subsequent valgus deformity 
(Fig. 796). To do this one should grasp the leg firmly, with one hand 
above the. ankle on the inner side and with the other hand seize the heel 
and foot ; then pull the latter forward, push it inward, and at the same 
time pull the leg outward. This procedure will thoroughly reduce the 
fragments and bring them into their normal relations. The foot and leg 
are then placed in a pillow and side splints up to the knee and held in this 
dressing until maximum swelling has ceased, which is about three to four 
days (Fig. 797). A suspended fracture-box is an exceedingly valuable 
dressing in fractures at the ankle. It is greatly preferred by Roberts to 
other means of support for the first two weeks. 

If a primary radiograph has not been taken, one should now be made 
in two planes if possible. If anatomical apposition of fragments is known 
to be present, the foot and leg are placed in a gypsum case, extending 
from the toes to just below the knee. In applying this case care should be 
taken to maintain the fragments in their normal position, the foot should 
be held at right angles to the leg and in a position of slight inversion 
(Fig. 798). The case should be split down each side, making an anterior 
and a posterior portion so that frequent observations may be made, or a 
single split down the front may be used to enable the surgeon to remove 
it every day or two. At the end of two and a half weeks a second case 
should be applied, the patient allowed on crutches, and at the end of from 
five to seven weeks the case may be discarded and an adhesive plaster 
dressing used, for maintaining support to the healing fracture. Weight- 
bearing should not be permitted until the end of eight or nine weeks 
on account of the possibility of distortion of the ankle as the callus is still 
soft. Careful massage and passive motion should be instituted from an 



65^ TREATISE OX FBACTUKES 

early period. Some surgeons believe not till the end of the fourth week. 
Others believe it better to begin cautiously a few days after the receipt 
of injury. The longitudinal arch of the foot should be maintained in 
ankle fractures and the length of the dorsum restored by complete reduc- 
tion of posterior displacement of the tarsal fragments of the tibia 
and fibula. 

After-results. — Good results should follow proper reduction and the 
maintenance of accurate apposition of fragments. Unfortunately, these 
cases are often improperly reduced, carelessly observed, and it is only 
when convalescence should be established that deformity is noticed. 
Convalescence is often prolonged by persistent oedema, stiffness of the 
joint, and atrophy of muscles clue to prolonged fixation. Haenel's statis- 
tics, quoted by von Bergmann, based on 40 cases, show 28 recovered (70 




Fig. 798. — Method of holding the foot and leg while a gypsum case is being applied. The 
foot should be slightly inverted, held at right angles to the leg and the leg supported by a 

sand-bag as shown. 

per cent.) ; 12 became disabled (30 per cent.), and the average loss of 
ensuing efficiency was about 50 per cent. These fractures, like fractures 
of the lower end of the radius, are often misunderstood and badly treated. 
Good surgery will, in many cases, prove its value and obtain by non-opera- 
tive means practically ideal results in function as well as in contour. 

Fracture of Fibular Malleolus with Fracture of the Posterior Articular 
Edge of the Tibia (Figs. 798-800(7). — This injury is no doubt a varia- 
tion of the typical fracture of the external malleolar region. It consists 
of a supramalleolar fracture of the fibula, usually about one and a half to< 
two inches above the tip of the malleolus, with fracture of the tibial 
malleolus and posterior articular surface of the tibia. 

Etiology. — The etiology of the fracture is the same as that of the 
typical fracture just described, but in addition there is usually some 
plantar flexion of the foot. 



FBACTUBES OF THE LOWER ENDS OF TIBIA AND FIBULA 655 

Mechanism. — In addition to the usual mechanism of fracture of the 
fibular malleolus, the trochlear surface of the astragalus is forced against 
the posterior edge of the tibial articulating surface and a fragment, usually 
consisting of the internal malleolus and posterior edge, is broken off. The 
tibial lesion may consist of two fragments, one the internal malleolus and 
the other the posterior articulating edge of the tibia. This condition is 
the exception. The anterior portion of the joint capsule is ruptured and 
the foot is not only dislocated inwardly, but also posteriorly, and usually 
is drawn upward by the calf muscles, so that in some instances the remain- 
ing articular surface of the tibia is displaced anteriorly to the trochlear 





Fig. 799. — Fracture of the fibular malleolus with fracture of the internal malleolus and 
posterior articular edge of the tibia. Posterior displacement of the foot. Anteroposterior 

and lateral views. 

surface of the astragalus and rests upon the head of the latter, with 
consequent shortening of the leg. 

Symptoms. — In addition to the usual symptoms of external malleolar 
fracture, there is marked dislocation backward of the foot. With this 
posterior displacement there is a marked tendency for recurrence, and 
there can be felt anteriorly the prominence of the anterior edge of the ar- 
ticulating surface ; in some cases there may be distinct dislocation in addi- 
tion to the fracture. Measurement from the inner tuberosity of the tibia to 
the tuberosity of the scaphoid will show shortening as compared with the 
other side. A radiographic examination should be made if practicable. 
The differential diagnosis from the usual fracture can ordinarily be made 
upon the tendency to prompt posterior and upward dislocation of the 
foot upon relaxing one's anterior pull of the foot. 



656 



TREATISE ON FBACTUEES 



Prognosis. — This depends in great measure upon primary recognition 
of the condition, and efficient treatment. Owing to involvement of the 
supporting surface of the tibia, there will be a more prolonged convales- 
cence; and function lessened when compared with the usual fracture in 
the malleolar region. 

Treatment. — Owing to the liability of recurrence of displacement of 
fragments after reduction, it is advisable to immobilize the foot and leg 
in a fracture-box after reduction and later to use a gypsum dressing, 
preferably a gypsum case, from the toes to the knee. Reduction should 
be performed under general anaesthesia. In addition to the method of 



Fig. 8ooa. 



Fig. 8oo&. 






Fig. 8ooa. — Fracture of the fibular malleolus, internal malleolus, and posterior articular edge of the 
tibia. Posterior displacement of the foot. Note the prominence of the anterior edge of the articulating 
surface of the tibia and evident shortening of the leg, due to upward and posterior displacement of 

the foot. 
Fig. 8oo&. — Fracture of the fibula, of the internal malleolus, and of the external articulating edge of 

the tibia. 

reduction described under the treatment of malleolar fracture, the foot 
should be carried also into a position of dorsal flexion. After the appli- 
cation of the gypsum case it should be split so as to form two splints, 
or a fracture-box should be so used as not to cause too great constriction 
and to allow daily inspection. The accuracy of anatomical reposition 
of fragments should be gauged by the radiogram or by frequent inspec- 
tion. Flexion of the knee in a swinging fracture-box or suspended an- 
terior wire splint, and even subcutaneous section of the tendon of Achilles, 
may be required to prevent recurrent displacement of the foot backward. 
Traction on the foot by means of a plantar footboard and pulley extension 
may be needed. Steinmann's nail traction from the heel may be used. 



FBACTUBES OF THE LOWER ENDS OF TIBIA AND FIBULA 65? 

Weight-bearing should be postponed for ten to fifteen weeks in severe 
cases or in heavy patients and then very cautiously permitted. 

Fracture of Fibula with Fracture of External Articular Edge of the 
Tibia (Fig. Sooa). — This is a rare fracture and must be considered as a 
variant of the fracture by eversion and abduction. 

Etiology. — This lesion generally is due to a fall from a height in which 
there is an eversion and abduction of the foot. The weight of the body 
is of chief importance in its production. 

Mechanism. — In addition to the mechanism described above under 
fibular fracture, there is the effect due to the weight of the body being 
applied simultaneously with the violence causing the supramalleolar frac- 
ture of the fibula ; by this force the outer trochlear surface of the astraga- 
lus is carried sharply against the outer portion of the articular surface of 
the tibia, by external rotation and abduction of the foot, so that either 
the tibiofibular ligament must give way or the outer edge of the tibia be 
broken away from the shaft. Dislocation upward of the astragalus be- 
tween the tibia and fibula may occur. 

Symptoms. — The symptoms of this fracture are those of a simple 
fibular fracture with, in addition, an unusual widening of the joint. This 
widening is due to the separation of the tibia from the fibula when there 
is rupture of the tibiofibular ligament, or separation of the outer tibial 
fragment from the remaining portion of the lower end of the tibia. Accu- 
rate diagnosis usually requires a radiographic examination. 

Prognosis. — The recovery of good function will depend entirely upon 
the completeness of reduction and the maintenance of accurate apposition 
of fragments until union is firm. 

Treatment. — On account of the possibility of upward and posterior 
displacement of the astragalus between the tibia and fibula, the primary 
retention of the leg and foot in a pillow and side splints after reduction 
is not advocated. General anaesthesia should be used for reduction, which 
is to be accomplished as in the usual fibular fracture. Subsequently immo- 
bilization should be secured by a gypsum case applied from the toes to 
just below the knee. The plaster-of- Paris encasement should be imme- 
diately split into anterior and posterior portions. 

Immobilization should last for at least six weeks and weight-bearing 
be allowed only cautiously at the end of about nine weeks. A swinging 
fracture-box for ten days or two weeks, followed by a circular gypsum 
encasement, is exceedingly satisfactory. Section of the tendon of Achilles 
may be used to prevent the displacing influence of gastrocnemius spasm. 

Inverted Fracture or Fracture of the Fibula by Inversion and Adduc- 
tion (Figs, 801 to 804). — This variety is not as common as fracture 
by eversion and abduction. 

Etiology. — The fracture is the result of indirect violence, and usually 
is due to a fall with the foot in a position of inversion or adduction. It 
occurs in missteps, in jumping, and in sudden force applied to the outside 
of the leg when the foot is fixed. 
42 



658 



TEEATISE ON FRACTURES 




/ 



s 




FEACTURES OF THE LOWER ENDS OF TIBIA AND FIBULA 659 

Mechanism. — Potentially this particular fracture should be frequent, 
because often one makes a misstep, the foot is inverted, and one feels a 
sharp, sudden strain at the point of attachment of the external lateral 
ligament. When fracture occurs there is a tear-fracture of the external 
malleolus and a pressure fracture of the internal malleolus due to forced 
inversion of the astragalus against the tibial malleolus. The line of frac- 
ture of the external malleolus is lower than that seen in the true fibular 
fracture with eversion, being usually transverse or slightly oblique, and 
occurring in a line continuous with the articular surface of the tibia; 
the line of fracture in the internal malleolus is higher than that seen in 
the eversion fracture, being triangular in shape and running from the 




Fig. 804.— A typical inverted Pott's fracture. Note the high and transverse line of fracture 

of the fibula. 



lower articular surface of the tibia upward and inward. At times a por- 
tion of the weight-bearing surface of the tibia may be included in the 
detached fragment. Displacements of fragments and of the astragalus 
are not nearly so frequent as in the eversion fracture. The foot is often 
held in a varus position. 

Symptoms. — The majority of these fractures show little displacement 
of the foot. When it is present it is always inward and there is also 
moderate inversion. Lateral mobility may be detected, as in the eversion 
fracture ; it is, however, not so pronounced and is always inward while in 
the eversion fracture it is outward. Posterior dislocation of the foot is 
extremely rare. There is localized pain and tenderness over the lower 
internal end of the tibia above the malleolus, and a small movable frag- 



660 



TEEATISE ON FRACTURES 



ment of bone may be palpated and crepitus is elicited. Over the external 
malleolus a loose fragment may also be discovered, but it is smaller 
than that seen in eversion fractures, and crepitus may be demonstrated 
by making lateral motion with the foot. There is generalized swelling 
about the joint and effusion within the joint. 

Prognosis. — These fractures usually should be followed with good 
functional results. There is not the same degree of injury to joint cap- 
sules and dislocation of fragments as there is in eversion fractures. Union 
occurs about the same time, and deformity is not so apt to be extreme. 
Efficient treatment is more likely to be obtained by the patient because the 
damage to soft parts and the tendency to displacement are less formidable. 



Fig. 805. 



Fig. 806. 




s 




Figs. 805 and 806. — -Isolated fracture of the internal malleolus. 



Treatment. — In the majority of cases there is little displacement of 
fragments. Reduction may be accomplished without general anaesthesia. 
Reduction is obtained by inward pressure above the ankle on the outer 
surface of the leg and outer pressure at the ankle and foot on the inner 
surface. The over-correction need not be used on account of the possi- 
bility of subsequent malposition. The foot should be placed at right angles 
to the leg. The foot and leg should be dressed with a pillow and side 
splint after reduction or in a suspended fracture-box; and this form of 
dressing should be used for three to four days. After this time the leg 
and foot should be kept in a moulded gypsum case, which should be split 
into anterior and posterior portions for observation of position. In frac- 
tures in which the internal malleolar fragment includes a part of the sup- 



FRACTURES OF THE LOWER ENDS OF TIBIA AND FIBULA 661 

porting tibial articular surface, it may be necessary to apply a gypsum case 
immediately after reduction on account of the tendency to recurrence of 
displacement of this fragment. 

Isolated Fractures of the Tibial, or Internal, Malleolus (Figs. 805 and 
806). — Isolated fractures of the internal malleolus are relatively infre- 
quent. Many cases are probably considered to be sprains. They are 
usually the result of a fall upon the foot when it is everted and abducted, 
or of a fall outward with the foot fixed. The injury in essence is of the 
same character as that seen in eversion fracture of the fibula, but it is 
not so severe a lesion. The osseous lesion is due to a forcible pull of 
the internal lateral ligament upon the malleolus, and the line of break 
usually is limited to the malleolus. At times only a small particle of 
bone is detached. There is very little displacement of the fragments and 
little if any deformity. In such cases sprain-fracture is a very appropriate 
term for the injury. 

Symptoms. — The usual symptoms are pain and tenderness limited 
to the region of the internal malleolus. There is generally a moderate 
degree of swelling in the region of the internal malleolus. Some lateral 
mobility of the foot may be possible in an outward direction, and with 
this movement crepitus may at times be developed. The lack of displace- 
ment of the fragment is due to untorn portions of periosteum or ligament 
holding the fragments together. Patients are often able to walk. 

Prognosis. — With proper reduction and immobilization a good ana- 
tomical and functional result is the rule. 

Treatment. — Owing to the absence of displacement in the majority of 
cases, the only treatment necessary is immobilization in a gypsum case 
until union is firm, which occurs in about five weeks. Cases of slight 
gravity may be treated with adhesive plaster straps carried around the 
instep and heel so as to give support, as in sprains of this region, If there 
is any displacement of the fragments of the malleolus, the same rules 
for reduction and immobilization hold good as given under eversion frac- 
ture. Care should be taken for some weeks to avoid slips during walking, 
which might throw strain on the union. If the lower fragment shows a 
marked tendency to displacement, it may, if comparatively large, be kept 
in position with a slender screw or nail. 

Isolated Fractures of the Lower End of the External, or Fibular, Mal- 
leolus (Figs. 807a and 807&). — Isolated fractures of the lower end of the 
fibula are frequent. They may be produced in two ways — by marked 
eversion of the foot as in the eversion already described, as a result 
oi direct pressure of the astragalus upon the external malleolus, or by 
inversion of the foot, thus partaking of the nature of a tear-fracture. In 
the first variety the line of fracture is usually about one and a half inches 
above the malleolus and may be oblique or spiral in direction; in the 
second form the fracture involves the external malleolus itself, and the 



662 



TREATISE OJST FRACTURES 



line is more transverse in direction and may consist of a tearing off of 
the tip or but a small piece of the cortex of the bone. 

Fractures by direct violence are extremely rare, and may involve any 
portion of the lower end of the bone. In only one of the above-mentioned 
types is there any tendency toward displacement. This occurs in the 
form due to eversion of the foot, where the line of fracture is well above 
the external malleolus. The astragalus may be slightly rotated outward, 
and the upper end of the lower fragment displaced inward toward 
the tibia. 

Symptoms. — The symptoms of fracture of the lower end of the fibula 
are localized pain, tenderness and swelling above the tip of the external 
malleolus. Crepitus may at times be discovered and abnormal mobility 



Fig. 807. 



Fig. 808. 





Figs. 807 and 808. — -Isolated fracture of the external malleolus. 

demonstrated by a finger placed on the extreme end of the lower frag- 
ment and rocking it inward and outward. When the fracture is limited 
to the very tip of the bony process, the only symptom present may be 
pain, tenderness and swelling limited to the malleolus. Some cases are 
very difficult to recognize from sprains. 

Prognosis. — The result, both anatomically and functionally, is 
usually good. 

Treatment. — As there is rarely any displacement of the lower frag- 
ment, treatment consists in the use of a gypsum case applied from the toes 
to just below the knee, after the maximum swelling has disappeared. 
This dressing should be used for four weeks, and after the first few days 
removed daily for massage and passive motion. After the fourth week 
a supporting dressing of adhesive plaster is all that is necessary. Weight- 



FKACTURES OF THE LOWER ENDS OF TIBIA AND FIBULA 663 




f ■ 




664, TBEATISE OX FKACTURES 

bearing may be allowed at the end of the fifth week, but for several 
weeks care should be taken to avoid sudden strains on the external or 
fibulotarsal ligament or the broken process caused by missteps in walking. 
A laced shoe coming above the ankle in malleolar fractures should be worn 
for some time after cure. 

Fractures of the Anterior Articular Edge of the Tibia (Figs. 
8o8a-8o8c) . — Fracture of the anterior articular edge of the tibia is an ex- 
tremely rare injury. In a patient seen by one of the authors, the injury 
resulted from the fall of a heavy beam upon the anterior region of the 
ankle-joint when the foot was fixed. 

Symptoms. — The symptoms of fracture are pain, swelling, and ten- 
derness limited to the anterior region of the ankle-joint. Flexion and 
extension of the foot demonstrate crepitus, and with plantar flexion 
abnormal mobility of the fragment may be determined. 

Treatment. — Reduction is accomplished by^ direct pressure backward 
of the displaced fragment, the corrected position maintained by immobil- 
ization of the foot and leg in a gypsum case, or an adhesive plaster 
cuff. A small pad or an indentation in the gypsum may assist in holding 
the fragment in place. Union occurs in from four to five weeks. Weight- 
bearing may be allowed at the end of five weeks. 

Summary 
reduction always first 

Upper End. — Fracture-box, not suspended, extending above knee; 
Cabot, lateral and posterior splints to control knee-joint in a similar 
manner; or a gypsum gauze encasement if not much swelling to be ex- 
pected. In longitudinal fracture of head of tibia may, if needed, use 
drill-pointed nail introduced through the skin to hold fragments in place. 

Shaft. — Suspended fracture-box or suspended anterior splints of wire 
rods ; suspended Thomas's knee splint with traction ; inclined-plane frac- 
ture-box ; Cabot posterior and lateral splints, lateral and posterior contour 
splints; or perhaps Buck's traction (with countertraction) from ankle, 
sole, or footboard of fracture-box. Gypsum encasement later. Division 
of tendon of Achilles occasionally. Operative treatment and fixation with 
steel plate in rebellious fractures. Occasionally direct fixation, after 
open reduction, with sutures, metal plates, bone dowels in medullary canal, 
autogenous inlays of bone graft. 

Lower End. — Suspended fracture-box; or perhaps Cabot lateral and 
posterior splints. Gypsum gauze encasement later. Do not permit weight- 
bearing early. Operative treatment occasionally for reconstruction of 
mortise- joint at ankle. 

Deformed union in tibial fractures should be treated, if bad, by osteot- 
omy for restoration of weight-bearing in normal line. 



CHAPTER XXVII 

FRACTURES OF THE TARSAL BONES 

Anatomy (Figs. 809-813). — The skeleton of the foot is divided into 
tarsal bones, metatarsal bones, and phalanges. There are seven tarsal 
bones : astragalus, or talus, calcaneum, or os calcis, cuboid, scaphoid, and 
the external, middle and internal cuneiforms. 

The astragalus is an irregular bone, consisting of body, neck and head* 




Astragalus 



Os calcis 



Cuboid 



v .y \ Tuberosity of 
"^M I fifth metatarsal 



Middle Xi'A ( i ' I £ 

cuneiform ffiM, V •• ^ 'y&j. l> 

1 



Internal 

cuneiform A'"''$ 



Base of first 
metatarsal 




Fig. 809. — Anterior view of bones of foot. (Davis.) 

Its body articulates above and laterally with the tibia and fibula and 
below with the calcaneum. The head in front forms a joint with the 
scaphoid bone. It has on the body above and at its sides the trochlear 
surfaces for forming the deep joint with the two malleoli and the lower 

660 



666 



TREATISE ON FRACTURES 



end of the tibial shaft. On the plantar surface is a deep groove for the 
tendon of the long flexor of the great toe, which curves around the poster o- 
inferior edge of the bone on the inner side of the ankle. 

The calcaneum is the largest of the tarsal bones and projects down- 
ward and backward to form the heel. It articulates with the astragalus 
by three articular facets, and with the cuboid. The various parts are 
the body, the tuberosity or posterior process, the internal and external 
processes, and a shelf-like process of bone which projects toward the 
astragalus and provides a facet for articulation with the same. 

The cuboid is placed on the outer side of the foot between the calca- 
neum and the bases of the fourth and fifth metatarsal bones. It is an 
irregular cube in form. The scaphoid is situated at the inner side of the 



Fig. 8106. 



For calcaneo- 
scaphoid lig. 

Calcaneum 




Internal tubercle — ^^ | ^^'-'-■mSlS Frt°rnn1 

tubercle 
Groove for tendon of flex. long. hall. 

Fig. 810c. — Right astragalus from above, showing 
articular surfaces for tibia and malleoli. 



Groove for flex, 
long. hall. 

External tubercle 

Fig. 810&. — Right astragalus from below, showing 
articular surfaces for scaphoid and calcaneum. 



foot between the astragalus posteriorly and the three cuneiform bones 
anteriorly. Its long axis is placed transversely to the long axis of the foot. 

The three cuneiform bones are placed between the scaphoid posteriorly 
and the bases of the first three metatarsal bones. They are wedge-shaped, 
the internal being the largest and the middle the smallest. 

Surface Markings. — Examination of the foot will show the following 
bony landmarks : Posteriorly may be felt the tuberosity of the calcaneum. 
Proceeding forward from this point on the external surface, palpation 
discloses the external tuberosity of the calcaneum, the external malleolus 
of the fibula, the tubercle on the peroneal ridge of the calcaneum about two 
and a half centimetres below the external malleolus, and the tubercle at 
the base of the fifth metatarsal bone. On the internal surface of the foot 
one may palpate the internal tuberosity of the calcaneum, the internal 



FRACTURES OF THE TARSAL BONES 



667 



malleolus of the tibia, the supporting shelf for the astragalus two and 
a half centimetres below the internal malleolus, the tubercle of the scaph- 

Fibixla ><V 



Calcaneus 
AfaUenlus Laleraus 



Sustentaculum tali 



Os cuboideusn. 



Ossa metatarsal: a 




Tibia 
Malt&oias medialte 



Os rutouuLire 

Os cuneiforms / 
Os melatarsale 1 



Fig. 8ii. — Outlines of bones of tarsus as shown in X-ray plates. Lateral view. 

oid about two and a half centimetres anterior to the internal malleolus, 
the internal cuneiform, and the prominence at the base of the first meta- 
tarsal bone. 




Fig. 812. — Rontgenogram showing bones of normal foot. Lateral view. 

Fractures of the Astragalus.— Fracture of the astragalus is frequently 
associated with fracture of the calcaneum or of the fibula, or with dislo- 
cation at the ankle-joint. 



668 



TREATISE OX FRACTURES 



Etiology. — Fractures of the astragalus are usually the result of great 
violence, which is occasionally direct; hence, they are often associated 
with severe injury to the soft parts, by which the fracture may even be 

made open. The fractures often 
are due to a fall from a height, 
in which the astragalus is broken 
by being crushed between the 
tibia and the calcaneum. Forci- 
ble dorsal flexion and direct in- 
juries, in which other fractures 
are produced, may also be the 
productive agency. 

Varieties. — Fractures of the 
astragalus may be divided as fol- 
lows : Fractures of the neck, 
fractures of the body, and frac- 
tures of the posterior (Stieda's) 
process. 

Fractures of the neck (Figs. 
814-817) are usually transverse 
in direction, and may be complete 
or incomplete. Usually there is 
very little displacement of frag- 
ments, unless the fracture is the 
result of great crushing violence, 
in which case there may be dis- 
placement of one fragment and 
associated fractures of other 
bones or severe injuries of the 
soft parts. The usual deformity 
in such cases is due to displace- 
ment of the body backward. 

Fractures of the body (Figs. 
818-821) of the astragalus fol- 
low no definite lines. The injury 
is usually comminuted, although 
at times there may be three defi- 
nite fragments consisting of head 
and neck, body, and the posterior 
process. Marked displacement of 




Fig. 



813. — Rontgenogram showing normal bones of 
foot. Anteroposterior view. 



the fragments is rare. 



Fracture of the posterior process (Fig. 822) occurs, but in some in- 
stances the supposed fracture of the posterior process is not a fracture. 
The apparent fragment is an anomalous bone, the " os trigonum," which 
occurs, however, in the lower vertebrates as a normal component of the 



FRACTURES OF THE TARSAL BOXES 



669 



n 



tarsus. In the human skeleton, however, this process is an integral part 
of the astragalus, and is subject to fracture, either independently or in 
association with other fractures of the astragalus or of the tibia or fibula. 

Symptoms. — In the absence of displacement of fragments the symp- 
toms of astragalus fracture consist of swelling about the ankle-joint, ten- 
derness on pressure limited to the region of the astragalus, pain upon 
attempt at weight-bearing and flexion of the foot. Crepitus may at times 
be detected by lateral motion. In some cases a positive diagnosis cannot 
be made clinically until swelling has ceased, and there is found evidence of 
callus, by palpation, and persistent limitation of motion at the ankle-joint. 

When there is actual displacement of a fragment, it generally may be 
felt by the examiner in its abnormal position. There is loss of contour 
of the normal ankle, at times marked 
limitation of motion, and, in com- 
pression fractures, the level of the 
malleoli is lower than normal. The 
foot is usually everted and a moder- 
ate degree of valgus is present. In 
fractures of the posterior process 
there is pain, localized tenderness, 
and thickening behind the internal 
malleolus ; at times crepitus and some 
limitation of motion. All suspected 
cases of fracture of the astragalus 
should be skiagraphed, and the 
variety of fracture and the degree 
of displacement of fragments there- 
by ascertained. 

Prognosis. — As the majority of 
fractures of the astragalus are unat- 
tended by any marked degree of de- 
formity, union should occur in a few 
weeks' time and the functional result should be excellent. When there 
is marked displacement of the fragments or comminution of the bone, the 
condition is serious as to satisfactory restoration of mobility of the ankle- 
joint. Staley collected 122 isolated fractures of the astragalus and 68 in 
which there were associated fractures of other bones. In 50 instances the 
displaced fragment or the entire astragalus was removed; amputation 
was performed in eight cases. In many of the severe fractures mobility 
at the ankle-joint is permanently impaired; occasionally necrosis of the 
unreduced fragment takes place. There may be permanent ankylosis, 
and in open fracture death may result from septicaemia. Von Bergmann 
considers that the earning capacity is impaired, at least, 15 to 20 per cent, 
or more, and on an average 30 per cent. 



\ 




Fig. 814. — Fracture of neck of astragalus 



6T0 



TEEATISE OX FRACTURES 




Fig. 815. — Compression fracture of neck of astragalus. 




Fig. 816.— Fracture of neck of astragalus. 

Treatment. — In fractures unattended by displacement of fragments 
treatment consists in immobilization in a gypsum case applied after maxi- 
mum swelling has subsided. The foot, if possible, should be placed at 
right angles to the leg and in slight inversion. The case should extend 
from the toes to just below the knee; it should be split down on both sides 



FKACTURES OF THE TAESAL BOXES 



671 



for observation of the soft parts and correction of unsatisfactory position; 
and at the end of two weeks massage and passive motion should be insti- 
tuted. Immobilization should be continued for from four to five weeks, 
and after this time should be replaced by an adhesive plaster supporting 
dressing. Weight-bearing usually may be instituted with caution at the 
end of the seventh week. 

In closed fractures attended by displacement of fragments a general 
anaesthetic should be given for reduction. By means of traction applied 
to the foot, and manipulation, it may be possible to obtain satisfactory 
reduction. If this is not possible, open operation should be performed, 
and the fragments reduced by leverage. When this cannot be effected, 
the displaced fragment should be removed. In open fracture attended 
by displacement of fragments, in which reduction is impossible, the 
troublesome fragments should be 
excised. Satisfactory functional re- 
sults may attend removal of part of 
the bone, and excision of even the 
entire astragalus may result in a fair 
degree of functional integrity. After 
operation, the treatment will consist 
of immobilization, followed by mas- 
sage and passive motion. Cases may 
occur, perhaps, in which a fragment 
showing a tendency to slip out of 
place after reduction could be nailed 
in position by a drill or nail thrust 
through the skin. It is left in that 
position under an aseptic dressing 
for two or three weeks. 

Results. — Staley reviews 122 iso- 
lated fractures of the astragalus from 
the literature ; 8 were direct frac- 
tures. In 18 cases the head was 
extirpated and in 31 cases the body 
was dislocated and was excised. In 
8 cases the entire astragalus was re- 
moved. One or other malleolus was broken in 11 cases and in 2 cases 
both malleoli were fractured. The calcaneum was fractured in 15 cases 
and in 2 cases it was entirely removed. Twenty-four cases succumbed 
to septicaemia. Eight of these were classified in the isolated cases and 
sepsis resulted from pressure necrosis. The foot was amputated in 8 
cases, and in 1 case both feet were amputated. 

Fractures of the Calcaneum. — Fractures of the calcaneum are the most 
frequent of the tarsal fractures. Formerly fractures of this bone were 
considered to be rare injuries, but the present frequent use of the Rontgen 



\ 




Si 7- — Fracture of external process of 
astragalus. 



672 



TEEATISE OX FEACTUBES 



ray in examining injuries of the lower leg and foot has demonstrated their 
comparative frequency. 

Etiology. — Fractures of the calcaneum happen as a result of falls 
from a height upon the foot, in which the weight of the body is transmitted 
through the calcaneum, from falls upon the foot plus muscular action 
of the calf muscles, from sudden contraction alone of the calf muscles, 
from direct violence, and from forcible inversion of the foot. 

Varieties (Figs. 823-832). — The following types of fracture are 
observed : avulsion, transverse, compression, and detachment of the sus- 
tentaculum upon which rests the astragalus. Avulsion fractures are due 
to sudden contraction of the gastrocnemius and soleus muscle with the 




A B 

Fig. 818. — Fracture of the body of the astragalus with outward dislocation of anterior fragment. 

foot in a flexed position. The line of fracture is not on the walking 
surface of the bone, the detached fragment consisting either of a con- 
siderable portion of the upper and posterior part of the posterior process or 
of a small cortical piece at the point of insertion of the tendon of Achilles. 
The displacement of the fragment may be very slight ; this is usually 
the case when the fragment is large. It may be extreme in those cases 
in which only a small cortical fragment is torn loose. The line of separa- 
tion may involve a portion, or the entire epiphysis, of the posterior proc- 
ess, causing an epiphyseal diastasis. Transverse fractures are due to direct 
violence. The line involves the walking surface of the bone, and usually 
runs from a point about midway on the upper surface downward and 
backward, so that a large posterior fragment is produced. This is rotated 



FRACTURES OF THE TARSAL BONES 



673 



about a transverse axis, the upper end of the posterior fragment being 
somewhat displaced upward while the lower anterior portion of the calca- 
neum is displaced somewhat downward. Marked displacement is limited 





Fie. 819. — Compression fracture of body of astragalus. 




/ 



Fig. 820. — Compression fractures of body of astragalus and of calcaneum with dislocation 
at astragaloscaphoid joint. 



by the attachment of the plantar fascia. Compression fracture occurs. 
These fractures may be recognized radiographically only by changes in 
the density of the shadow, in the shape of the os calcis or of its typical 
lamellar structure, and the evidence of unusual angularity of the bone. 
43 



674 



TREATISE OX FRACTURES 



In the more severe types of this fracture distinct compression, comminu- 
tion and displacement of fragments may be readily recognized. The 




Fig. 821. — -Compression fracture of body of astragalus. 




Fig. 822. — Fracture of the posterior process of trie astragalus. 

favorite site of this fracture is the anterior half of the bone; in some 
cases the fracture line involves the entire calcaneum. Irregularity of com- 
minution of fragments is characteristic and vertical compression usual. 



FBACTUBES OF THE TAESAL BONES 



675 



Such fractures are usually the result of falls upon the foot and only 
rarely of direct violence. The astragalus seems to act as a wedge and is 



Fig. 823. 




A 



\ 



Fig. 824. 



S 




Figs. 823 and 824. — Types of tear-fracture of the posterior process of the calcaneum. 

forced through the calcaneum. The degree of compression and of com- 
minution is in direct ratio to the distance of the fall and the weight of the 
patient. Associated fractures of the malleoli are occasionally seen. The 



676 



TREATISE OX FRACTURES 



Fig. 825. 



X 



/ 




Fig. 825. — Type of tear-fracture of the posterior process of the calcaneum. 
Fig. 826. 




Fig. 826. — Type of fractures of posterior process of calcaneum. 



FRACTURES OF THE TARSAL BONES 



677 



Fig. 827. 




Fig. 828. 




^ 




Figs. 827 and 828. — Types of fracture of posterior process of calcaneum. 



site of the lesion is dependent, to a great degree, upon the position of 
the foot at the time of injury. Fractures of the shelf on which the 
astragalus rests (sustentaculum tali) are usually associated with fracture 
of other portions of the calcaneum. Isolated fractures of the sustentacu- 



TREATISE OX FRACTURES 

Fig. 829. Fig. 830. 




Fig. 831- 




Figs. 829, 830, and 831. — Types of compression fractures of the calcaneum. 

lum are extremely rare. The fracture results from a fall upon the foot 
when it is in position of marked inversion. The resulting- deformity is 
a pes valgus. 

Plagemann's statistics of 17 isolated fractures of the calcaneum show 
10 compression fractures of the entire body of the calcaneum with a partial 



FBACTUBES OF THE TARSAL BONES 



679 



\ 




Fig. 832. — Fracture of epiphysis of posterior process of calcaneum. 




Fig. 833. — Method of determining lateral normal motion in the foot. 

or complete tearing off of the sustentaculum tali ; 4 fractures of the pos- 
terior process ; 2 fractures of the anterior portion and body, and 1 fracture 
of the posterior process and body of the calcaneum. In 4 of these 17 



680 



TREATISE ON FRACTURES 




A B 

Fig. 834.— Fracture of left calcaneum, anterior and posterior views. Note loss of normal contour, 
and widening of calcaneum region, with tendency to flattening of the anteroposterior arch of the foot. 

cases there was an associated fracture of the astragalus, consisting twice 
of a fracture of the neck, once a fracture of the posterior process, and once 

a fracture of the posterior process 
and neck of the astragalus. In these 
cases the fracture line of the calca- 
neum was a continuation of the frac- 
ture line of the astragalus. 

Symptoms. — The frequency with 
which fracture of the calcaneum is 
overlooked is due in a great measure 
to the fact that unless there is marked 
displacement of fragment the. symp- 
toms are slight and unattended by 
absolute disability. Careful inspec- 
tion and examination should render 
the diagnosis positive in the majority 

Fig. 835. — Cotton s method of reduction of a frac- r J J 

tUre ^p^rdSpic^ment'o / th^ fragment" 1 Whh ° f CaSeS > and in the remaining thlS 

may be done by the use of the ront- 
genogram. The characteristic symptoms are swelling in the region 
of the astragalus and about the ankle, thickening posterior to the 
midtarsal region, usually on the internal and external surface of 
the foot below the malleoli, and marked limitation or at times entire 




FRACTURES OF THE TARSAL BONES 



681 



absence of lateral motion of the foot (Fig*. 833), although flexion and 
extension at the ankle-joint are free. Cotton lays great stress 
upon the thickening found, in nearly all fractures of the body of the 
calcaneum, on the external surface of the bone beneath the external mal- 
leolus, and considers it to be due to the detachment and forcing outward 
of a thin cortical fragment from spreading of the bone beneath it. At 
times there is upward displacement of the posterior fragment with corre- 
sponding flattening of the foot, so that a valgus position is present. 

In many cases the weight of the body 



Crepitus at times may be detected. 




Fig. 836. — Cotton's method of correcting lateral broadening below the malleoli by compression of fragments 

with a hammer and piece of felt. 

can be borne upon the injured foot. In severe compression fractures 
the malleoli may be nearer to the sole of the foot than is normally present. 
There are in addition localized pain, tenderness on pressure, ecchymosis, 
and usually characteristic broadening below the malleoli, seen best from 
a posterior view (Fig. 834). In avulsion fracture the displaced fragment 
may generally be felt in its abnormal position. When practicable, radio- 
graphic examination should be made to determine not only the variety of 
fracture but also the degree of displacement of fragments and to reveal 
associated lesions of other bones. 



682 TEEATISE ON FBACTURES 

Prognosis. — In fractures unassociated with displacement of fragments 
the prognosis is good as regards function. The same cannot be said 
of fractures in which there is comminution or displacement of fragments. 
In these cases non-operative methods of treatment are apt to be attended 
by poor functional results and marked decrease in earning efficiency. This 
is due to loss of the arch of the foot, to the projection of fragments into 
the sole of the foot, making walking painful, to loss of lateral motion 
of the foot, and to pain due to relaxation of ligaments. 

Treatment. — In fractures unattended by displacement of fragments 
treatment consists in immobilization in a gypsum case applied from the 




Fig. 837. — Fracture of the body of the calcaneum with upward displacement of the fragment. 

toes to below the knee for a period of three to four weeks. If there is 
upward displacement of a posterior fragment, the knee should be kept 
flexed to relax the calf muscles, and the foot held in extension. This may 
be done by a gypsum encasement from mid-thigh to the toes. The knee 
may be kept flexed by means of a long strap of adhesive plaster attached 
to the thigh and the middle of the leg. This is to be associated with, or 
followed by, massage and passive motion; weight-bearing should be 
allowed at the end of six or eight weeks. In many cases, however, there 
is displacement of fragments. Four usual forms of displacement are 
amenable to treatment by reduction. A general anaesthetic is usually 
required for reduction of fragments. If displacement cannot be -corrected 
by traction and manipulation, operative measures should be adopted. 



FRACTURES OF THE TARSAL BONES 



683 



In fractures attended by upward displacement of the posterior process 
reduction may be accomplished by the introduction of a spindle through 
puncture holes just in front of the point of insertion of the tendon of 
Achilles as suggested by Cotton (Fig. 835). Traction is made on this 
spindle and the fracture reduced. If reduction cannot be maintained, 
tenotomy of the tendon of Achilles, either alone or combined with nailing 
of the fragments in their normal position, should be done. After reduc- 
tion, immobilization with the foot in slight plantar flexion of the ankle 
in a gypsum case should be used. Fractrfres attended by lateral broaden- 
ing below the malleoli should have this displacement corrected by Cotton's 




Fig. 838. — Drawing to show the pull exerted by the tendo Achillis in fracture of the posterior portion of 
the body of the calcaneum. (Made after rontgenogram Fig. 837). 

operative method (Fig. 836). This consists in placing the inner surface 
of the foot upon a sand-bag, and protecting the outer surface of the 
calcaneum by a felt pad. After this precaution, reduction of displaced 
fragments is accomplished by repeated blows with a wooden mallet, creat- 
ing impaction of the fragments. A gypsum case is used after reduction. 
In fracture attended by displacement of sharp fragments from the weight- 
bearing surface of the calcaneum, which are thrust into the plantar 
muscles, open operation should be the plan of procedure, with excision of 
these fragments. 

Fractures attended by upward displacement of a portion of the pos- 
terior process due to pull of the tendon of Achilles may require open 



684 



TREATISE OX FEACTUEES 



operation, if flexion of the knee and extension of the ankle, or tenotomy 
of the tendon of Achilles, prove unsuccessful. This -consists in exposure 
of the fragments through a curved posterior incision, approximation of 
the fragments, and suture with kangaroo tendon. Tenotomy of the ten- 
don of Achilles may also be necessary (Figs. 837-839). 

Fractures of the Tarsal Scaphoid. — Fractures of the tarsal scaphoid 

( Figs. 840-845 ) are rather rare 
injuries and usually are the result 
of direct violence, in which there 
may be associated also fractures 
of other bones of the foot. These 
fractures may be comminuted and 
open, or may partake of the 
character of avulsion fractures. 
Fractures by indirect force are 
due to falls upon the foot in 
which the foot is in a position 
of plantar flexion and the weight 
is received upon the toes. As 
a result the scaphoid is crushed 
between the astragalus and the 
internal cuneiform. In a few 
instances the fracture is the re- 
sult of a twist of the foot or a 
misstep. The insertion of the 
posterior tibial muscle into the 
bone accounts for some of the 
tear- fractures of the tubercle of 
the scaphoid. The usual site of 
fracture is the tubercle, although 
in fractures due to direct violence 
any portion of the bone may be 
the seat of injury. Usually there 
is a moderate degree of dis- 
placement of the fragment of 
the tubercle; in some instances 
the dorsal fragments may be 
pushed upward under the ten- 
dons on the dorsal surface of the foot. 

Symptoms. — The symptoms of fracture of the tarsal scaphoid depend 
in some degree upon the site of fracture. There is always marked pain 
and tenderness on pressure over the inner and dorsal surface of the 
instep, that is, in the region of the scaphoid. Pain is increased by weight- 
bearing. Some local swelling and possibly ecchymosis are present. The 
foot presents a valgus position, and abduction is usually marked. Pain 




Fig. 839. — Method of approximation of fragments in 
fracture of posterior portion of body of calcaneum bv 
open operation. The fragments are secured by two in- 
terrupted sutures of kangaroo tendon passed" through 
drill holes in the bone and the torn periosteum is united 
by interrupted chromic catgut sutures and the skin by 
interrupted linen thread. Immobilization is maintained 
by a gypsum case. 



FRACTURES OF THE TARSAL BONES 



685 




686 



TKEATISE OX FBACTUBES 




j* 



* , - 





c3 

c 

u 

y 

la 

° 

y y 

d o3 

1.2 

"^f-i 
°°. I 

M <* 
fooO 




FBACTUKES OF THE TARSAL BONES 687 

is usually referred up the leg along the course of the posterior tibial 
muscle, and on account of the attachment of this muscle to the tubercle 
of the scaphoid the latter is pulled inward; the antagonistic peroneus 
muscles pull the foot into a valgus position, and after a time rigidity of 
the foot in the valgus position results. Forced abduction of the foot 
increases pain at the site of fracture, as this motion separates the frag- 
ments of the scaphoid. Displacement of fragments will usually be recog- 
nized by palpation. When severe compression or dislocation of fragments 
is present, the inner measurement of the foot is shortened. Suspected 
cases should be radiographed. Occasionally there is a sesamoid bone in 
the tendon of the posterior tibial muscle; its presence should not mislead 
one into assuming the presence of fracture. Examination of many radio- 
graphs leads to the belief that the tubercle of the scaphoid is not developed 
from an individual centre of ossification. 

Prognosis. — In the majority of unrecognized and unreduced cases 
of fracture of the tarsal scaphoid, traumatic flat-foot is the result. Severe 
compression fracture of this bone is followed by markedly poor function 
and a painful, weak foot. 

Treatment. — When there is no marked displacement of fragments, 
treatment consists in immobilization of the foot and leg in a gypsum 
splint for three to four weeks. The foot splint should be applied with 
the foot in moderate inversion and adduction. Slight massage should 
be performed from the beginning of treatment or from the end of the 
second week, and weight-bearing allowed at the end of the sixth week. 
Cases complicated by marked displacement of fragments demand open 
operation, reduction or excision of fragments, and later immobilization. 
Most of the patients should use a felt pad for supporting the arch of the 
foot for several months. Metal arch supports are not recommended. 



CHAPTER XXVIII 

FRACTURES OF THE METATARSAL BONES AND 

PHALANGES 

Fractures of the Metatarsal Bones 

Anatomy. — Of the five metatarsal bones each has a base, a shaft, and 
a head. The first metatarsal is the largest and the second the longest. 
The bases of the first and fifth metatarsal bones present a broad projection 
called the tuberosity. The first metatarsal bone has the development of 
a phalanx, that is, an epiphysis at the base. The other metatarsals have 
their second centre of ossification for the head. This method of develop- 
ment corresponds with that seen in the hand. The first metatarsal occa- 
sionally shows evidences of having an ossific centre for the head of the 
bone as well as the usual one at the base. This tendency to ossification 
by three nuclei in the first metatarsal recalls the similar circumstance in 
the first metacarpal. These facts should be borne in mind in studying 
roentgenograms of foot and hand for evidences of fractures in patients 
under twenty years of age. 

Surface Markings. — The first and fifth metatarsal bones can be readily 
and the other three fairly well palpated throughout their entire length. 
The tuberosity of the fifth metatarsal is prominent on the outer surface 
of the foot. 

Statistics. — Plagemanns statistics show 49 fractures of the metatar- 
sals in 1393 cases, distributed as follows : First metatarsal, 9 times ; second 
metatarsal, 12 times; third metatarsal, 3 times; fourth metatarsal, 4 
times; fifth metatarsal, 9 times; first and second metatarsals, 4 times; 
first, second, third, fourth and fifth metatarsals, 2 times; first, second 
and fourth metatarsals, once; second and third metatarsals, 3 times; 
fourth and fifth metatarsals, once; and first, second and third metatar- 
sals, once. 

Etiology. — Fractures of the metatarsal bones (Figs. 846-852) are 
usually the result of direct violence, as from falling objects, and crushing 
injuries, and occasionally from indirect violence, as in jumping and pro- 
longed marching. Fractures of the fifth metatarsal, while occasionally 
produced by direct violence, are usually due to a sudden throwing of the 
weight of the body upon the foot, when the latter is in a position of inver- 
sion, as in dancing, jumping from a moderate height, or in. a misstep. 

Symptoms. — Fractures from direct violence are generally accom- 
panied by considerable bruising of the overlying soft parts, so that there 
is marked swelling, localized pain, tenderness on pressure, and ecchymosis. 
They are often open and therefore contaminated and infected. Crepitus 
688 



METATAESAL BONES AND PHALANGES 689 

Fig. 846. Fig. 847. 





Fig. 846. — Comminuted fracture of the first metatarsal. 
Fig. 847. — Comminuted fracture of the first metatarsal, longitudinal in type. 



Fig. 848. 



Fig. 849. 






Fig. 848. — -Transverse fracture of the first and second metatarsals. 
Fig. 849. — Longitudinal fracture of the first metatarsal. 

can frequently be detected and the fragments may be moved in any 
direction. Some of these fractures can be determined positively only by 
the radiogram, and many of them are overlooked. After swelling of 
the soft parts has disappeared, displacement of fragments can be recog- 
nized. The lines of fracture may be oblique, transverse, or comminuted, 
44 



690 



TREATISE ON FRACTURES 



m % * 





-6% 2 
« 8 5 



(» «= P 






0) a a> 

O io o 

5 I? 

goo | 

S ,: <n 




METATABSAL BONES AND PHALANGES 



691 



and rarely are longitudinal. Multiple fractures are frequent. Longi- 
tudinal fractures are seen only in the first metatarsal. 

Of particular interest are fractures of the fifth metatarsal. Isolated 
fracture of this bone, when not the result of direct violence, is due to 
inversion of the foot under the weight of the body. It is produced by 
direct pressure upon the outer part of the foot. As the foot is turned 
inward and the weight of the body brought upon the outer surface of 
the foot, strain is brought to bear upon the base of the bone, which is 
held firmly to the fourth metatarsal and cuboid bones by strong ligaments. 
As a result of this strain, fracture usually occurs at the base. The follow- 
ing varieties of fracture may be recognized : Fracture through the tip of 
the tuberosity (Figs. 853-855) ; fracture through the base of the tuberos- 
ity (Figs. 856 and 857) ; transverse fracture through the proximal end 



Fig. 853. 



Fig. 854. 



Fig. 855. 




# W Z MM r' iflHL 

Figs. 853. 854, and 855. — Types of fractures of the tip of the tuberosity of the fifth metatarsal. 

of the shaft (Figs, 858 and 859) ; and fracture through the shaft of the 
bone (Figs. 860-864). 

The symptoms of inversion fracture of the fifth metatarsal are local- 
ized pain, tenderness on pressure, partial disability, localized swelling, 
and pain referred to the seat of fracture upon lateral squeezing of the 
foot just above the heads of the metatarsals. Crepitus may at times be 
determined, particularly when the line of fracture occupies the shaft of 
the bone (Fig. 865). Radiograms will make a positive diagnosis, although 
in many cases it may be made from the character of the injury and the 
localized tenderness, pain, swelling, and late ecchymosis. 

Prognosis. — Fractures by direct violence are usually attended by 
marked displacement of fragments. Unless such displacement is reduced, 
union takes place with deformity, and there is the presence of a marked 
projection, either dorsally, which gives considerable discomfort on account 
of shoe pressure, or the fragment may be displaced into the plantar region 
of the foot, with secondary nerve pressure and consequent disability. In 



692 



TREATISE OX FRACTURES 



fracture of the fifth metatarsal by inversion, union usually occurs with 
very little deformity and the functional results are good. 

Treatment. — Reduction of fragments should be accomplished by trac- 




FlG. 




Figs. 856 and 857.— Types of fracture of the base of the tuberosity of the fifth metatarsal 
Fig. 858. Fig. 859. 




Figs. 858 and 859. — Types of fracture through the proximal end of the shaft of the fifth 

metatarsal. 

tion and manipulation. Anteroposterior displacements should always be 
corrected, even if open operation is necessary. Immobilization after re- 
duction should be by means of a well-moulded plantar gypsum splint or 
a carefully padded wooden splint. The corrected position may be diffi- 



METATARSAL BONES AND PHALANGES 



693 



cult to maintain. The fragments may then be nailed together with a 
wire nail or steel drill driven through the tissues by hammering. A 
preliminary puncture may be made in the skin, if necessary. If incision 



Fig. 860. 



Fig. 861. 









Fig. 862. 



Fig. 863. 





Figs. 860, 861, 862, and 863. — Types of fracture of the shaft of the fifth metatarsal. These 

fractures, when caused by inversion of the foot, are spiral in character. When due to direct 

violence, they are usually transverse or oblique in character. 



is required to facilitate reduction, fixation should be accomplished by 
direct suture with chromic catgut followed by the use of an external 
gypsum splint. Immobilization, with frequent light massage, should be 



694 



TREATISE ON FRACTURES 

W 





Fig. 864. — Type of fracture of the shaft of the fifth metatarsal. 




Fig. 865. — Method of determining abnormal mobility and crepitus in fracture of the shafts of the 

metatarsals. 
Fig. 866. Fig. 867. 




Fig. 866. — Transverse fracture of the proximal phalanx of the great toe. 
Fig. 867. — Oblique fracture of the proximal phalanx of second toe. 



METATARSAL BONES AND PHALANGES 



695 



2 00 

00 n o> 

»J rt 00 

1 G I 

w 

°El 

MP 

o ?J 

aaS 



•3 < n> 




/ 





696 TREATISE ON FRACTURES 

continued for from four to five weeks. Weight-bearing may be instituted 
at the end of six or seven weeks. 

Old cases, in which there is union with deformity and loss of function 
due to pressure, call for operation and excision oi projecting spurs 
of bone. 

In fractures of the fifth metatarsal by inversion there is little dis- 
placement of fragments, and treatment consists in immobilization by a 
gypsum encasement or splint for four weeks. 

Fractures of the Phalanges 

Fractures of the phalanges (Figs. 866-870) are the result of direct 
violence. Exceptions to this statement are those fractures which occa- 
sionally result from stubbing the toe; in these the force is received on 
the point of the distal phalanx. These fractures may be subcutaneous 
or open; and complicated by comminution, contamination and infection. 
The line of fracture may be transverse, oblique, longitudinal or irregular. 
Of particular interest have been two cases observed by Kelly. One con- 
sisted of a fracture of an exostosis of the distal phalanx of the great toe, 
and the other a longitudinal fracture of the distal phalanx of the great toe 
involving epiphysis and diaphysis, the result of direct violence. Open com- 
minuted fractures are frequent from crushing of the toe by machinery 
or impact of heavy objects on the foot. 

Symptoms of phalangeal fractures are localized pain, swelling, ecchy- 
mosis, tenderness on pressure, crepitus, and abnormal mobility. 

Treatment. — Displacement of fragments is rarely great. Reduction 
is readily accomplished, and immobilization made either by strapping the 
toe to the adjoining one, or by using a plantar splint. Union occurs in 
three to four weeks and functional results are good. 



CHAPTER XXIX 

FRACTURES OF THE SMALL SESAMOID BONES 

Anatomy. — Sesamoid bones are small osseous structures developed 
in tendons; and are situated at places where tendons play over joints, or 
are subject to considerable pressure upon underlying cartilaginous facets 
of bones. They make their appearance about the twelfth year. In early 
life they are cartilaginous but become bony. As these small structures 
may be ossified or represented by fibro-cartilage, they will not be disclosed 
by X-ray examination in the young. When seen by fluoroscope or in 
X-ray plates, ossified sesamoids may be mistaken for fragments due to 
fracture. This circumstance renders knowledge of their usual sites impor- 
tant. One surface of the bone is usually covered with cartilage ; the bone 
may enter into the formation of the joint, or be separated from the latter 
by a bursa. The rest of the sesamoid bone is buried in the tendon. Many 
of the sesamoid bones are constant, are ossified in adolescence and adults, 
and as such show by radiography and fluoroscopy. When formed of fibro- 
cartilage they show no shadow. The largest sesamoid is the patella. 

The constant sesamoid bones (Figs. 871-874) of the hand are those 
occurring at the metacarpophalangeal joint of the thumb. They are two 
in number, are joined together by fibrous tissue, and form the floor of the 
groove of the flexor longus pollicis tendon. 

The constant sesamoid bones of the foot (Fig. 875) are two in 
number and are situated on the plantar surface of the head of the first 
metatarsal bone near the metatarsophalangeal articulation. They are 
united by fibrous tissue and form the floor of the groove for the tendon 
of the flexor brevis muscle. 

Of the inconstant or accessory sesamoid bones of the hand, may 
be mentioned the following : There is sometimes found a third or acces^ 
sory sesamoid at the metacarpophalangeal joint of the thumb, also one 
at the interphalangeal joint of the thumb; one between the flexor tendon 
and the head of the second metacarpal; one between the flexor tendon 
and the head of the fourth metacarpal, and one between the flexor tendon 
and the head of the fifth metacarpal. Two accessory sesamoids have 
been noted at the head of the fifth metacarpal and accessory carpal sesa- 
moids in flexor tendons at the wrist. 

Fawcett's statistics, based upon rontgenologic examination of 38 pairs 
of hands, show the sesamoids in the index-finger in 55.2 per cent.; in 
the fifth finger in 71 per cent., and in the interphalangeal joints of the 
thumb in 69.3 per cent. 

Geist examined the feet of 100 persons who never had an injury or 
foot complaint, and of these there were 30 presenting accessory sesamoid 

697 



698 



TEEATISE OX FRACTURES 






Fig. 871. 



Fig. 872. 



' \ 




Fig. 871. — Constant sesamoid bones of the thumb. 

Fig. 872. — Shows only one constant sesamoid bone at the metacarpophalangeal joint of the thumb, 

one accessory sesamoid at the head of the second metacarpal, one at the head of the third metacarpal, 

and two at the head of the fifth metacarpal. 



Fig. 873. 



Fig. 874. 





<* 



f 



Figs. 873 and 874. — Shows two accessory carpal sesamoid bones in tendon sheaths of flexor tendon 

to fifth finger. 

bones, which he divides as follows : Important group : os trigonum, os 
tibiale externum, os peroneale, and os Vesalii. Unimportant group : sec- 
ondary os calcis, os intermetatarsale, and os intercuneiforme. 

The os trigonum (Figs, 876 and 877) is situated at the back part 
of the astragalus. It may be small or large, double or single. The so- 
called Shepherd's fracture as a rule is nothing more than this os trigo- 
num. This bone was found 7 times in this series, was always unilateral, 



FBACTUBES OF THE SMALL SESAMOID BONES 



699 



while in 3 of the 7 cases a larger posterior process was noted in the other 
foot. The os tibiale externum (Fig. 878) was formerly considered as 
accessory bone in the tendon sheath of the tibialis and situated behind and 
slightly below the tubercle of the scaphoid. It is often unilateral and is 
often mistaken for a fracture of the tubercle of the scaphoid. Fourteen 
cases were seen in the series of 100; single in 9, double in 5. On one 
side there may be an absolutely loose tibiale externum, and on the other 
side it may be represented by a large tubercle of the scaphoid. The os 
peroneale (Fig. 879) is apparently a true sesamoid bone, being situated in 
the tendon of the peroneus longus muscle. It was found present in 



Fig. 87.5. 



Fig. 876. 





Fig. 875. — Constant sesamoid bones at head of the first metatarsal bone. 
Fig. 876. — Type of os-trigonum. This is often mistaken for the so-called Shepherd's fracture of the 

posterior process of the astragalus. 

7 cases, being single in 3 and double in 4 cases. In two of these cases 
it was bipartite. 

The os Vesalii is situated at the base of the fifth metatarsal bone. It 
is very rare and was found once in 100 cases. The secondary os calcis 
occurs extremely rarely. In this series it was found twice. When pres- 
ent it may simulate a broken off part of the sustentaculum tali. The inter- 
cuneiform is a small wedge-shaped bone situated between the internal and 
middle cuneiform bones. It was found in two cases. The intermetatarsal 
is considered by Dwight to occur in 10 per cent, of all cases. It is difficult 
to recognize by radiograph and is found between the bases of the first 
and second metatarsal bones. 

Pfitzner found sesamoid bones on the fibular side of the fifth toe in 
6.2 per cent.; on the tibial side of the fifth toe in 5.5 per cent., and on 
the tibial side of the second toe in 1.8 per cent. 



TOO 



TREATISE OX FRACTURES 



Occasionally there is observed 
moids of the great toe a third or 




Fig. 877.— Type of os trigonum. This is often 

mistaken for the so-called Shepherd's fracture of 

the posterior process of the astragalus. 

Fig. 87S. 




Fig. 878. — Os tibiale externum, in the tendon 
sheath of the tibialis posticus tendon. 



Fig. 879. 




Fig. 879- — Double os peroneale, situated in the 
tendon of the peroneus longus muscle. 



in addition to the two constant sesa- 
accessory sesamoid. Frequently there 
is seen an apparent fracture, particu- 
larly of the tibial sesamoid of the 
great toe, which is considered by 
many authorities to be an anomalous 
division of the sesamoid in two parts. 
This may be definitely ascertained at 
times by having radiographs of both 
feet taken not only in anteroposterior 
planes but also laterally. An unusual 
situation of accessory sesamoid is in 
the tendon of the gastrocnemius 
muscle (Fig. 880). Pancoast con- 
siders that it is present in about 12.5 
per cent, of cases and usually found 
in the outer head of the muscle. It 
has been mistaken for a loose body in 
the popliteal bursa or in the knee- 
joint. Accessory sesamoids are also 
found at the heads of the metatarsal 
bone. A sesamoid bone may be de- 
veloped in the iliopsoas muscle 
where it slides over the pubic bone; 
one may occur in the biceps tendon 
of the arm at the point where it lies 
against the tubercle of the radius; 
and one may be encountered in 
the great gluteal tendon where it 
glides upon the great trochanter of 
the femur. 

Etiology. — Fractures of the sesa- 
moids other than the patella have 
been observed involving those of the 
thumb and the great toes. These 
fractures in the great toe (Figs. 882— 
887) result from direct violence, 
such as jumping on the toes, run- 
over accidents, sudden falls upon the 
feet, and the impact of falling objects 
on the foot. Fractures of the sesa- 
moids of the thumb (Figs. 888 and 
889) may be the result of catching 
rapidly moving objects, such as a 
baseball, or they may accompany 



FBACTUBES OF THE SMALL SESAMOID BONES 



701 



dislocation at the metacarpophalangeal and interphalangeal joints. Stumme 
(quoted by Mutter) showed on the cadaver that fracture of the tibial sesa- 
moid bone may be produced by forcible dorsiflexion with abduction. 
Symptoms. — The symptoms of fracture of the sesamoid bones of the 



Fig. 


880. 






Fig. 881. 








-.'■• '* * ; 








• 




. 








• . -■'V 








V 












m 








Ik / 




[/III 










H 




r 








^T 




J 



Fig. 880. — Accessory sesamoid in the tendon of the gastrocnemius muscle. 

Fig. 881. — Shows the two constant sesamoids at the head of the first metatarsal, and accessory sesamoids 

at the heads of the second, third, fourth, and fifth metatarsals. 



./ 



\ 





A B 

Fig. 882. — Comminuted fracture of the tibial sesamoid of the great toe. Run over by motorcycle. 

Anteroposterior and lateral views. 

great toe are persistent pain and tenderness on walking on the plantar 
surface of the foot over the region of the sesamoids ; it is usually the tibial 
sesamoid bone. In addition there is generally history of an injury either 
from a direct fall upon the foot or by a falling weight striking the foot 



02 



TREATISE OX FRACTURES 



over the sesamoid region of the great toe. Similar symptoms are caused 
by fracture of manual sesamoids. An absolute diagnosis may be made 
only with the radiogram, which will show the dentated margin of frac- 





A B 

Fig. 883. — Fracture of the tibial sesamoid of the great toe. Injured while playing basket-ball. 



Fig. 884. 



Fig. 885. 




Fig. 884. — Fracture of fibular sesamoid, accompanying comminuted fracture of the head of the first 

metatarsal. Injured by a falling weight striking foot. 

Fig. 885. — Fracture of the tibial sesamoid. Form of injury not ascertained. 

ture. Anteroposterior and lateral views of both feet should be made 
for a comparison so as to avoid diagnosing an anomalous division of the 
sesamoid as a fracture. Occasional ossification of portions of tendons 
near joints may be mistaken for sesamoids, and fractures of osteophytes 



FBACTUBES OF THE SMALL SESAMOID BOXES 



703 



may be erroneously diagnosticated as broken sesamoids, and vice versa. 
The mistake of confounding sesamoids in the gastrocnemius tendon be- 
hind the outer condyle of the femur, in the biceps below the elbow-joint, 



Fig. 886 




\ 



Fig. 886. — Fracture of the fibular sesamoid. Run over by a motorcycle. 
Fig. 887. — Fracture of the tibial sesamoid. Injured while playing baseball. 



Fig. 888. 




Fig. 888. — Old fracture of interphalangeal sesamoid in a baseball player. 

Fig. 889. — Fracture of the sesamoid of the thumb. Patient fell upon extended thumb. 

(Courtesy of Dr. P. G. Skillern, Jr.) 

or in the iliopsoas tendon at the pubes for a fracture must be avoided by 
remembering the possibility of their occurrence in these sites. 

Treatment. — This consists in immobilization of the foot or hand upon 
a moulded gypsum plantar or palmar splint for three or four weeks. 
If pain and soreness on use of the hand or in walking persist, excision 
of the fragment should be performed. 



CHAPTER XXX 

OBSTETRIC FRACTURES 

Fractures which occur during birth are termed birth or obstetric frac- 
tures. They are observed rather infrequently. E. D. Truesdell, in a 
study of about 9000 cases delivered at the New York Lying-in Hospital, 
has found 14 fractures of the humerus, 10 fractures of the clavicle, and 
2 fractures of the femur. He later reports a separation of the lower 
femoral epiphysis, and G. W. Kosmak, from the same institution, reports 
four cases of depressed fractures of the skull. 

Obstetric fractures, sometimes well called fractures of the new-born, 
require treatment similar to that of the like lesions of bone in children of 
older years. There is less tendency to muscular displacement of the frag- 
ments because the weak musculature acts as a soft padding rather than as 
a displacing agency. Union in good position occurs rapidly, if care is 
taken to keep the broken bone from angular displacement. Union may 
be expected in three or four weeks. Plastic splints of gypsum and gauze 
will in general be available and useful. 

Obstetric fractures must be differentiated from fractures happening 
before the foetus is expelled from the uterus. These intra-uterine breaks 
of the skeleton are usually found to be united when the child is born. 
At times the union has occurred with the fragments in bad position. 
Such a vicious union may need operative treatment by re fracture 
or osteotomy. 

Depressed Cranial Fractures — Etiology. — Depressed fractures of the 
cranium in the new-born occur in difficult labor and are the result of 
pressure from forceps in instrumental delivery or of some projecting 
deformity in the pelvis. Defective ossification of the bones may be a 
contributing cause of the fracture. 

There are frequently areas of subdural hemorrhage and of oedema 
after difficult labor with or without forceps delivery, but in time these 
areas disappear by absorption without any permanent injury to the brain. 
In depressed fracture of the cranial bones this does not readily occur. 
Although at times the brain may accommodate itself to small areas of 
permanent depression, subsequently these deformities of the surface of the 
skull may exert a deleterious effect on the functions of the brain. The 
cranial dents sometimes disappear by reason of the elasticity of the par- 
tially ossified wall of the cranium ; as a rule they persist and may leave the 
patient the subject of nervous disturbances, such as epilepsy, idiocy, and 
other cerebral changes. Birth fractures of the cranium are usually 
either furrow-like indentations, near the anterior fontanelle, or spoon- 
shape depressions. The former are, as a rule, of no great moment and 
704 



OBSTETEIC FRACTURES 705 

may disappear in one or two weeks. They are more frequently due to 
pressure of obstetricians' forceps in a difficult labor than to- pressure from 
irregularity or narrowness of the birth canal. The spoon-shape depres- 
sions of the cranium are more serious ; and occur from pelvic deformity, 
causing obstruction to labor at the sacral promontory or the iliopectineal 
eminence and a resulting prolonged instrumental delivery. These injuries 
are serious and may give rise to convulsions, muscular spasms and death. 

Symptoms. — In some of the cases there will be entire absence of 
symptoms, excepting the presence of the depressed area of bone. If the 
depression is sufficiently marked to cause compression, or over important 
cerebral centres, the respirations may be slow and labored, the heart action 
slow and weak, and irritative or paretic symptoms arise. The child may 
not cry, and the pupils may be unequal and fail to react to light. Partial 
asphyxiation may be present, and there may be at first muscular twitch- 
ings or paralysis, depending upon the degree and extent of the depressed 
area or its location over motor centres. 

In all cases of prolonged labor, contracted pelvis, or instrumental 
delivery, the head of the child should be carefully examined for areas 
of depressed fracture. The presence of a marked caput succedaneum, 
the cedematous swelling of the tissues over the skull which have not 
been subjected to pressure during passage through the birth canal, may 
conceal an area of depressed fracture. When it is present, repeated 
examination should be made. When areas of depression are found to 
persist, they should be elevated promptly by operation, for it is unwise to 
expect intracranial pressure to force the depressed area of the cranium 
out to its normal contour. 

Treatment. — When an area of depression is found, correction should 
be made as soon as recognized. Sometimes gentle pressure made 
anteroposteriorly will cause the osteomembraneous cranium to spring 
into its normal shape. This may be an unwise procedure. Kosmak 
has devised an instrument for the correction of depressed frac- 
tures of the skull, which consists of a hook with, a handle. The 
hook is placed at a right angle to the shaft of the instrument and is 
mounted on a handle for convenience in using. The hair over the de- 
pressed area is clipped with scissors, the area painted with tincture of 
iodine, and the point of the instrument forced by firm and constant pres- 
sure into the centre of the depressed fracture. When the point has pene- 
trated the inner table of the skull, the handle of the instrument is turned 
at right angles to the surface and steady traction made outward until the 
depressed area is elevated. A sterile dressing and bandage complete the 
operation. A small trephine may be used to gain admission for an ele- 
vator which can then be used to prize up the depressed portion of the 
cranial vault. If there is any doubt as to the necessity for operation, 
it is better to turn up a flap of scalp, cut out a small button of bone with 
trephine and restore the normal shape of the calvarium. The little disc 
45 



706 



TREATISE OX FRACTURES 



of bone should be replaced before closing the wound in the soft tissues. 
It is to be recollected that the bone is very thin in an infant. It may be 
almost membranous, so that with scissors one may readily raise a trap- 
door flap to examine the brain. 

Fracture of the Humerus— Etiology.— Truesdell's observations upon 
fractures of the humerus in the new-born show, of the 14 cases observed, 
that 10 occurred during version and breech extraction, 3 during simple 
breech extraction, and 1 in spontaneous vertex delivery in which diffi- 
culty was met in extracting the anterior arm on account of a narrowed 
pelvic outlet. 

The line of fracture in 13 of these cases was transverse in direction, 
near the centre of the shaft, or just below the insertion of the deltoid 

muscle; in the other case the 
fracture was produced by the 
application of a fillet to the pro- 
lapsed arm in a shoulder presen- 
tation followed by traction upon 
the limb while version was 
being performed. The fracture 
was produced by torsion of the 
arm across the child's back. 
The line of fracture in this case 
was oblique. 

Deformity. — In the major- 
ity of cases this was primarily 
absent but later occurred, either 
by the child's muscular efforts 
or by the manipulations of the 
nurse in handling the child. 
The deformity then assumed 
one of external angulation. In 
a few cases there • was lateral 
deviation of fragments. Over- 
riding of fragments was extremely rare (Fig. 891). 

Every fracture of the humerus observed by Truesdell was accom- 
panied by wrist-drop. This is considered to be due either to pressure 
upon the musculospiral nerve occurring before the production of the 
fracture, or to entanglement of the nerve between the fragments. In two 
cases which died he was able to examine the seat of fracture ; and in neither 
of these two was there any evidence of violence to the brachial plexus 
or the musculospiral nerve. In one case he noted the occurrence of an 
Erb birth palsy in the injured arm. 

Symptoms. — The presence of fracture of the humerus may be readily 
recognized by the evident disability to use the arm, deformity, localized 
pain at the seat of fracture, and crepitus. Perhaps wrist-drop from 
paralysis, as mentioned above, may be present. 




Fig. 



890. — Obstetric fracture of clavicle and humerus. 
Union taking place. 



OBSTETBIC FBACTUBES 707 

Treatment — Prophylaxis. — While Kosmak considers that fracture of 
one of the long bones is never a very serious lesion in comparison with 
depressed skull fractures, he thinks that it is desirable and often possible 
to avoid the complication by correct diagnosis of the exact position of the 
arms of the child before the body is born. A correction of the brachial 
malposition is then attempted before extraction of the child. He urges 
that so soon as the umbilicus is born in a breech extraction with or without 
previous version, the fingers of the examining hand should be introduced 
over the posterior vaginal commissure and the position of the arms in 
relation to the head determined. If the arms are extended, or one of 
them is caught behind the neck in the form of a nuchal hitch, it is much 
easier to sweep them over the face into a position of flexion then than to 
attempt this manoeuvre after the greater portion of the trunk has been 
born. At this time the head has not been wedged into the pelvic 
entrance, and the arms, if extended, can usually be released without much 
difficulty. It has not been found practical to rely on any flexion of the 
arms being maintained through pressure exerted on the fetal head through 
the lower abdominal segment. Nearly always the arms will become 
extended during version, and this fact might as well be recognized before 
the posture of the arms becomes a source of danger to either mother 
or child. 

In the treatment of these fractures the difficulty of maintaining immo- 
bilization of fragments is apparent. The simplest form of treatment 
consists in surrounding the arm with coaptation splints, and fixing the arm 
and forearm to the chest by means of a bandage applied to the shoulder 
and arm as suggested by Velpeau. Union occurs in about three weeks. 
Truesdell has devised a splint made of sheet aluminum, cut and folded 
in such a manner that the external angular deformity is corrected. 
The splint at the same time fixes the arm to the body, flexes the elbow, 
and entirely immobilizes the arm. In treating fractures of children of 
this early age care must be exercised to avoid chafing of the tender skin 
by the pressure of bandages and splints. The constant likelihood of soil- 
ing the dressings and fracture apparatus by urine and faeces must be 
relieved by frequent changes of splint padding, bathing the skin and dust- 
ing with non-irritating powders. A straight splint of light wood, metal, 
or wire cloth, as long as the distance from elbow to elbow when the 
child's two arms are fully abducted, makes a satisfactory fixation dressing. 
It should have a right-angle extension at both ends to support the fore- 
arms. This double rectangular splint is to be applied across the back of 
the child and keeps the broken humerus at rest in a comfortable posture. 

Truesdell concludes from an observation of his cases that union is 
prompt in birth fractures of the humerus, complicating injuries are usually 
insignificant, and lateral displacement even if marked is not unfavorable. 
He thinks angular deformity should be guarded against or corrected if 



708 



TKEATISE OX FKACTUEES 



possible, but that when uncorrected, and even when excessive, nature will 
do much to remedy the defect during the first years of life, effecting a 
final result never possible under corresponding conditions in an adult 
patient. Fractures of the shaft of the femur may do well by hyperflexing 
the knee and holding the limb thus with a bandage or an adhesive 
plaster strap. 

Fracture of the Clavicle — Etiology. — Of the 10 cases observed by 
Truesdell, 8 occurred during version with breech extraction, i during 
forceps delivery, and I during a normal vertex delivery. The latter was 




Fig. 891. — Fractures of right humerus and both clavicles. The fracture of the humerus is situated at 

its centre, the usual site; the line of fracture is oblique. The outward rotation of the lower fragment 

may be prevented by fixation of the forearm to the front of the chest wall. (Courtesy of Edward D. 

Truesdell, M.D., New York Lying-in Hospital.) 

unrecognized at the time of birth, and later attention was called to its 
presence by the pressure from callus. 

The site of fracture (Fig. 891) is usually about the middle or at the 
junction of the middle with the outer third. In most of the cases dis- 
placement was very slight, and in those in which it was moderate it 
assumed that seen in corresponding fractures in the adult. 

Treatment. — The majority of cases will do well with maintenance of a 
corrected position by a posterior figure-of-8 bandage or by a Velpeau 
claviculohumeral bandage holding the upper end of the humerus upward 



OBSTETEIC FRACTURES 709 

and backward. The double-armed dorsal splint of Spitzy accomplishes 
this object quite well. It is made of pasteboard, is applied to the back 
of the child, and held against the head, neck and shoulders with adhesive 
plaster; the forearms are bandaged to its lateral projections and hold 
the two humeri backward. 



10 WEEKS 




Fig. 892. — Fracture of shaft of femur, at end of ten weeks, show- 
ing union, uncorrected anterior angulation, and large and firm 
callus. (Courtesy of Edward D. Truesdell, M.D., New York 
Lying-in Hospital.) 

In one case, reported by Truesdell, union failed to occur at the end 
of the fifteenth month, and a false joint had formed at the seat of fracture. 

Fracture of the Femur. — Fracture of the. femoral shaft and one of 
separation of the lower femoral epiphysis were observed by Truesdell. 

Etiology. — Fracture of the femur may occur during version and in 
breech extraction. The shaft may be broken or the lower epiphysis 
suffer disjunction. 

The symptoms of fracture of the shaft of the femur (Fig. 892) are 
those usually seen in fracture of the shaft in the adult. In separation of 



710 



TREATISE OX FRACTURES 




Fig. 893. — Radiograph of the normal and injured femur for comparison. In the normal bone the lower 
epiphysis with its nucleus of bone is shown occupying its usual position. In the injured femur the lower 
epiphysis has been displaced backward and upward, its position being indicated by the contained ossifi- 
cation nucleus. The periosteum has been stripped up from the lower portion of the shaft of the bone 
and beneath this new bone formation is already taking place. (Courtesy of Edward D. Truesdell. M.D., 

New York Lying-in Hospital.) 




Fig. 894. — At the fourth month the new-formed femur compares quite favorably with its fellow of the 
opposite side. The new and original portions of the femoral shaft differ but slightly in density. Indi- 
cations of the new internal and external condyles are evident, the ossification nucleus occupying its 
usual position in the depression between them. (Courtesy of Edward D. Truesdell. M.D., New York 

Lying-in Hospital.) 



OBSTETRIC FRACTURES 



711 



the lower femoral epiphysis (Figs. 893 and 894) the deformity will 
depend upon the degree and direction of displacement. Skiagraphs will 
aid in the diagnosis of obstetric diastases when the ossific nucleus has 
already appeared in the epiphysis, supposed to be displaced by injurious 
manipulations during labor. 

Of the fractures of the shaft, Truesdell treated one by splints and 
bandages without any attempt at extension. Then the patient disappeared 
from observation before union had occurred. When seen at the end of 
eighteen months, there was 
firm union, anterior angular 
deformity, shortening, and a 
decided limp. 

Truesdell reports a 
femoral break in which the 
fracture was not observed 
until one month after its oc- 
currence. Union was then 
firm, there was external and 
anterior angular deformity, 
shortening, and abundant 
callus. In a case of separa- 
tion of the lower femoral 
epiphysis, full reduction of 
fragments was impossible. 
Callus formation occurred 
along the course of the 
stripped off periosteum, 
which was attached to the 
lower epiphysis and detached 
from the junction of the 
middle and lower thirds of 
the shaft downward. This 
resulted in the formation of 
a new shaft and condyles, 
with atrophy of the denuded 
portion of the shaft. 

Treatment. — In all fractures of the shaft of the femur correction 
of the deformity should be performed and immobilization made with a 
suitable dressing which includes traction if necessary. A good dressing 
is that described by Truesdell (Fig. 895). 

Spitzy has recommended an anterior inverted V-shape splint of 
malleable iron strips applied to the front of the trunk and legs. At the 
middle of the child's sternum the point of the inverted V is placed, the 
two metal strips are bent to conform to the contour of chest, abdomen, and 
the flexed thighs, legs and feet. The splint is padded and kept in place with 




Fig. 895. — Aluminum splint used in obstetric fracture of hume- 
rus: (A) part secured behind back by adhesive plaster; (B) part 
behind shoulder; (C and D) flaps which fold about arm, press 
upper fragment inward and lower fragment outward. The 
splint is lined with canton flannel or sheet wadding. (Courtesy 
of Edward D. Truesdell, M.D., New York Lying-in Hospital.) 



712 



TREATISE OX FRACTURES 



gypsum or adhesive plaster around chest, knees, legs, and middle of 
thighs. The abdomen and upper parts of thighs are not included in 
the retentive dressing. Soiling of the apparatus is thus avoided. 

Another method, very simple in its character, is to use the baby's body 




Fig. 896. — Long side splint used in fracture of shaft of femur. The use of this splint should correct external 

angular deformity and afford traction. Coaptation splints may be used about the thigh. (Courtesy of 

Edward D. Truesdell, M.D., New York Lying-in Hospital.) 

as a splint by flexing the thigh on the abdomen and maintaining that 
posture with a swathe of muslin. 

Fractures of the Bcnes of the Leg and Forearm. — The ulna and radius 
and the tibia and fibula are not likely to be broken during labor. Hence 
there has been little opportunity given for study of these lesions in new- 
born infants. Should such fractures occur in babies, fixation with 
moulded splints of gypsum and gauze or any rigid material of light weight 
will be found satisfactory for fixation. 



CHAPTER XXXI 

INDUSTRIAL AND WAR FRACTURES 

War produces some fractures identical with those seen in civil life. 
The increased activity in building, manufacturing, transportation, and 
engineering then arising demands unusual energy and celerity and causes 
accidents. The treatment of these fractures does not differ from that 
demanded in ordinary civilian practice. The injuries of bone, received 
in battle from projectiles used to lessen an enemy's efficiency, deserve, 
however, special surgical consideration. These are like those seen in 
industrial traumatisms by machinery, railroads, and explosives. 

A fracture is a sudden solution of continuity by violence dividing 
the shaft or epiphysis into pieces, destroying its anatomic and physiologic 
integrity. Less injuries of contour are also fractures; but incomplete 
fracture seems a better term. Injuries to bone by projectiles frequently 
show portions torn away from the surface, or holes of penetration or 
perforation. Such wounds do not interfere mechanically with the func- 
tion of the long bones as sustaining structures or levers for transmitting 
motion. Some military writers therefore prefer to use the term " wound " 
of bone for these incomplete fractures, restricting " fracture " to the more 
serious lesions in which there occurs solution of continuity of the main 
part of the individual bone. Leriche, for example, says, though inaccu- 
rately, that there is no fracture of the shaft of a bone unless its con- 
tinuity is broken, meaning that there must be a complete section of the 
shaft. His statement rests evidently on a pathological differentiation 
of the lesions due to> the fact that gunshot injuries of shafts of tubular 
bones are unlike those produced by the same missiles in the epiphy- 
seal ends of the bone. The anatomical distribution of cancellous 
and compact tissues in the diaphysis varies from that in the epiphysis. 
The association of the latter portion with a joint renders modification 
of treatment necessary. War-fractures of the extremities may be divided, 
with good reason, into two groups : diaphyseal and epiphyseal. They are 
as a rule caused by missiles of small size, with high velocity, striking 
a limb and coming in contact with its bones. The bone struck may be 
penetrated, perforated, or have a superficial portion torn away, showing 
a groove, a hole, a tunnel, a fissure, or complete separation of parts of 
the bone. 

Gunshot fractures (Figs. 897-916) are relatively infrequent in civil 
life. Those seen are inflicted by accident or with homicidal or suicidal 
intent. The usual weapons are revolvers, pistols, shotguns, occasionally 
a small rifle, and very rarely the military rifle. The type of revolver used 
is generally of moderate calibre and is not as powerful as the heavy service 

713 



714 



TREATISE OX FRACTURES 



weapon. Fractures by the military rifle occur in civil life from attempts 
at suicide, and as the weapon is held near the body the character of injury 
is entirely different from that seen in military life, where the wounds 
are inflicted at considerable distances. This statement is, however, modi- 
fied by the fact that the firearms used by sportsmen are becoming more and 
more like those used in military service. The arms of civil life, however, 
have usually missiles of less weight and calibre, lower velocity, and less 
energy than those of the soldier. 

The characteristics of a bullet wound depend upon the velocity of 
the missile, its size, the distance it travels before impact, its mode of 
impact, its stability, and the resistance of the part struck. 






Fig. 897. — Makins's five types of fracture observed in military life: (.4) stellate fracture; (B) irregular 
stellate fracture; (C) typical complete wedge fracture; (D) incomplete wedge fracture; and (E) oblique 

single line fracture. 



The usual type of weapon producing fractures in civil life is 
the revolver, usually of a .32 or a .38 calibre. The projectile from 
this weapon has no great velocity, the distance travelled by the mis- 
sile is short. The injury is often characterized by a wound of en- 
trance without a wound of exit. There is damage in the track of 
the bullet, perhaps deformity, and the bullet, possibly fragmented 
or distorted by contact with bone, is lodged under the skin at a point 
opposite to the point of entrance. Frequently the bullet can be detected 
beneath the surface by careful palpation. During the deer and bear hunt- 
ing season, fractures from shotguns loaded with heavy shot or from 
rifle bullets are seen by surgeons in civilian practice. Mining, railroad 
accidents, machinery mishaps, and automobile collisions expose workmen, 
passengers and bystanders to complicated fractures essentially equivalent 



INDUSTRIAL AND WAR FRACTURES 715 

to infected breaks and crushes of bone seen by the army and 
naval surgeons. 

Industrial injuries from explosions of dynamite and similar agencies 
represent quite well analogous fractures and wounds of soft parts result- 
ing from shell, shrapnel, and hand grenades used in war. The foreign 
materials driven into the soft parts and bone increase the similarity to 
military fractures. 




Fig. 898. — Gunshot fracture of the palate and the body of the sphenoid bones. Wound self-inflicted by 

a 32-calibre bullet, which passed through the palate bone and lodged in the body of the sphenoid bone. 

Patient recovered. Anteroposterior view. (See Fig. 899.) 

Makins gives five types of fracture (Fig. 897) which are observed 
in military life; these are simulated to some extent in civil life. 

Stellate fracture : The bullet perforates the bone centrally and from 
the bullet tract four oblique fissures radiate to the surfaces of the bone, 
separating a wedge-shaped fragment from each side, and causing the ends 
of the main fragments to be pointed. This is commonly termed the 
" butterfly " fracture. The irregular stellate fracture, due to low degree 
of velocity of bullet : Here there is suppression of the two left-hand limbs 
with the substitution of a transverse line of fracture. 

Typical complete wedge fracture. Incomplete wedge fracture : In 



716 TREATISE OX FRACTURES 

this variety the line of fracture is oblique or lateral and the two left-hand 
lines of the stellate fracture are suppressed. 

Oblique single line fracture : In this variety one right-hand and one 
left-hand line of the stellate fracture are suppressed. The weight of the 
body probably has some influence in the production of this type. To 




Fig. 899. — Gunshot fracture of the palate and the body of the sphenoid bones. Wound 

self-inflicted by a 32-calibre bullet, which passed through the palate bone and lodged in the 

body of the sphenoid bone. Patient recovered. Lateral view. (See Fig. 898.) 

fully recognize these types by radiogram the rays should be directed in the 
exact line of the track of the bullet. 

While many of the gunshot fractures may be stellate in character, 
marked comminution is present and the lateral main fragments are broken 
up into numerous smaller fragments. Perforated fractures are par- 
ticularly observed when the fracture occupies the epiphyseal end of a 
bone; comminution is apt to be absent here on account of the small pro- 
portion of compact bone in this locality. 

Fractures from gunshot usually have a wound " open " to the 



INDUSTRIAL AND WAR FRACTURES 



717 



skin surface. This complication constitutes a " compound " fracture. 
Such should be expected to be contaminated, unless known to be pro- 
duced by a rifle bullet or a shrapnel bail. These missiles usually do not 
carry pieces of clothing or other foreign material into the wound; hence 
they do not always infect the tissues. 




Fig. 900. — Perforating gunshot fracture of the frontal and the nasal 
bones. Small fragments of lead may be seen imbedded. 

Gunshot fractures are apt to be comminuted; and radiating fissures 
may extend long distances. These quite often extend from or through 
epiphyses into joints. The velocity of the missile frequently is imparted 
to the comminuted portions of bone; and so the soft structures may be 
pulpined by a multitude of secondary missiles created after the projectile 
has pierced the skin. This occurs less readily when an epiphysis is 
struck by the bullet, because the spongy bone composing it does not 
shatter as does the compact tubular shaft. An insignificant wound of 



718 



TREATISE OX FRACTURES 



entrance may lead into a large cavity filled with a soft mixture of particles 
of bone, blood-clots, and mushy muscle surrounding the broken femur 
or humerus. This " explosive " action must not be forgotten. 

The character of a fracture received in battle varies with the nature 
of the missile. Rifle bullets travel with high velocity. They cause split- 
ting fractures of shafts and simple perforations of the cancellous 
epiphyses. If the bullet has been changed in shape, by previously hitting 
another object, or tumbles, it may not split the bone, but act more like 
a fragment of shell-casing. Pieces of shell, because of slow progress 




Fig. 901. — Gunshot fracture of the mandible. 

through the air, may cause fracture by impact or merely penetrate a 
short distance into the bone. Projectiles which have glanced from objects 
hit before making a wound are more apt to infect the fracture. Con- 
taminated material is liable to be picked up by the first contact. Shell, 
bombs, and grenades usually cause infected fractures. 

Penetrating and perforating fractures are more serious than impact 
fractures. Infection is liable to be carried into the medullary cavity of 
the bone and the bacterial products then are imprisoned within bony walls. 



INDUSTRIAL AND WAR FRACTURES 



719 



These products lead to septic complications, drainage is defective, and 
antiseptic instillation difficult. Necrosis and general septicaemia are not 
uncommon results. Small wounds of entrance and exit may, in such 
cases, greatly deceive the surgeon as to the risk to life and induce him 
to give a. favorable prognosis. Infection of a fracture means a prolonged 









902. — Gunshot fracture of the left humerus. The bullet is lodged in the 



convalescence and demands most wise and energetic treatment. Com- 
minution does not necessarily delay union. It probably hastens it, because 
more centres of medullary activity supply callus. 

The displacement of fragments in all comminuted fractures is toward 
the exit side, which is due to the propulsive effect of the tmll-et. Slight 
lateral displacement may also occur from the wedge action of the bullet as 
it traverses the bone. In many of the gunshot wounds of civil life the 



720 TREATISE OX FRACTURES 

fracture is characterized by little if any displacement of fragments, but 
by imbedding of the bullet in the bone and by fragmentation of the bullet. 
In fractures produced by shotguns the distance travelled by the shot is 
very short and as a rule the shot strikes as a compact mass. Marked 
comminution of fragments is characteristic. Gutter and groove fractures 
may be considered as incomplete perforations, the roof of the terminal 
being absent. They are rarely seen in the shaft, but more commonly in 
the articular ends of the bone. Sometimes a fracture may occur in two 




Fig. 903. — Gunshot fracture of the humerus; note butterfly type of fracture, 
and fragmentation of the bullet. 

regions of a single bone, one from the missile and be infected, the other 
from the fall due to the general effect or the impact of the projectile. 

The present European War has served to change somewhat radically 
surgeons' views in regard to gunshot wounds received in warfare. The 
mutilating character of shell and shrapnel injuries and the coincident life 
of the soldier in trenches produce with great frequency severe comminu- 
tion of bone accompanied by crushing of the soft parts and immediate 
infection with pyogenic and perhaps tetanus and gas bacillus organisms. 
Such lesions are comparable to machinery and railroad crushes of limbs 
so frequent in civil life. These lesions are air-exposed, and, therefore, 
may be called infectious osteomyelitis almost from the reception of injury. 
The English term, " compound " comminuted fracture applied to open 



/ 



INDUSTRIAL AND WAR FRACTURES 721 

fractures of this kind, is scarcely descriptive, nor is infected comminuted 
fracture sufficient. " Infected pulpified fracture " might be a better term. 
Such injuries, whether obtained in military service or otherwise, present 
far different problems from other complicated fractures. 

The passage of railroad trains over limbs, and squeezing given persons 
caught in machinery, between colliding vehicles or under falling rocks 
or walls cause open comminuted fractures with crushing and defiling of 
the soft parts and bones. These fractures are pulpified, contaminated, and 
infected. They give rise to deep shock, serious hemorrhage, septic infec- 
tions, gangrene, and death in a way not unlike war fractures. The loss of 
bone substance sustained may, if life be saved, lead to non-union, deform- 
ity or prolonged suppuration with 
pus-containing cavities within a 
massive callus enclosing necrotic 
bone. They are like war fractures j| 
of the same character and require 
like treatment. Amputation pri- 
marily or secondarily is often neces- . Wm B 
sary to save life or to maintain a ^^Je* 
partial degree of function by means l 
of prosthetic appliances. 

Industrial surgeons will gain 
much by adopting the measures 
found useful in military hospitals for f ^PT 1 

the relief of similar complicated 
fractures. There may be much more ^ 

damage to overlying soft parts in the 

crushing fractures due to heavy , V. 

grinding pressure just described - \ 

than occurs when the comminution L 

i • r , • r I-. ,1 • , 1 Fig. 904. — Gunshot fracture of the carpus. 

and infection follows the internal 

explosive effect of a bullet shattering the shaft of a bone ; but when 
infection has developed the symptoms and treatment are very like in 
both instances. 

Symptoms. — The symptoms of gunshot fracture are pain and shock. 
The former depends upon the site of fracture and of the wound of 
entrance, the sensitiveness of the individual, and the mental preoccupation 
of the patient at the time of injury. The shock varies greatly with the 
site and seriousness of the fracture. In perforated fractures without 
comminution or loss of continuity of bone, diagnosis will depend upon 
the line of the bullet and the radiographic examination. In complete 
fractures there will be abnormal mobility of fragments and crepitus, which 
at times may be difficult to elicit on account of fragmentation and separa- 
tion of the ends of the bone. In suspected fractures, radiograms in two 
planes should be taken. 

Gunshot fractures depend upon the character of the projectiles. The 
46 



'22 



TREATISE OX FRACTURES 



modern service rifle has small calibre and projects a jacketed bullet of 
lessened diameter compared with the bullets formerly used. Thus the 
velocity of the projectile is increased, and its trajectory relatively flat, 
though the revolution of the projectile on its long axis is increased by 
reason of its length. The severity of the wound produced by this bullet 
decreases in indirect proportion to the distance of the object struck from 
the muzzle of the rifle; that is, the greater the distance, the less the injury. 
The more pointed the bullet the greater is its penetrating power, and 
its ability to perforate bone. Bullets of low velocity have less penetrating 
power than those of high velocity. Thus it is that less injury is done 
the greater the distance from the muzzle of the rifle. Bullets of low 



Fig. 90s. 



Fig. 906. 




Fig. 905. — Gunshot fracture of the carpus. 
Fig. 906. — Gunshot fracture of the proximal phalanx of middle finger. 



velocity may lodge in the tissues without being deformed, because they 
have little penetrating power. A bullet which strikes an object before 
entering the skin may ricochet and, being deformed by the first impact, 
will probably cause more damage than a bullet which has not ricocheted. 
Soft spongy bone allows perforation by reason of its lessened resistance 
more readily than compact bone. The bullet track is like a hole bored in 
soft wood. Compact bone is more split up, and the broken particles, 
acting as secondary missiles from assuming the unexpended velocity of 
the arrested projectile, greatly increase the explosive effect of the bullet. 
The skin wound of entrance and that of the underlying soft parts 
may be trivial in appearance, while the bone itself is greatly damaged. 
The bone shattered into fragments may greatly lacerate the soft tissues 
near it, especially on the side opposite the point of impact. This corre- 



INDUSTRIAL AND WAR FRACTURES 



723 



sponds with the usual well-known smaller wound of entrance of bullets of 
low velocity and the greater size of the wound of exit. A missile travelling 
with great velocity and meeting little resistance makes a narrow track with 
small entrance and small exit wound with little deflection within the tissue. 
The experience of military surgeons with rifle wounds such as have 
just been described proves that the jacketed small-calibre bullets of high 
velocity cause less dangerous wounds, though they temporarily disable the 
soldier. Smokeless powder is said -to add to the humanity of gunshot 
wounds from small arms. 

Complications. — The complications of gunshot fractures are infection, 
and injury to blood-vessels, nerves, tendons or muscles, or lesions of 
proximal or distal viscera. In pulpified and com- 
minuted fractures infection with pyogenic, gas bacillus, 
and tetanus germs is frequent in war zones, and in a 
fair number of similar fractures re- 
ceived in quarries, mines, and other 
locations where workmen come in 
contact with soil teeming with bac- 
terial life. 

The modern change in shape of 
bullets has influenced the character 
of the wound in bones as well as soft 
parts. Soft lead bullets, and even 
hardened lead bullets which are jack- 
eted, are liable to change shape when 
striking the bone and therefore, 
whether deflected or perforating, do 
more damage to hard and soft tissues. 
Bullets composed of a single piece 
suffer less change from contact with 
This change in shape, when it occurs, gives rise to more 
splinters, a larger wound of the soft parts and bone, and by making the 
fragments of bone secondary missiles, enlarges the wound of exit more 
than would otherwise be the case. 

The extensive comminution of gunshot fractures which occurs espe- 
cially in shafts is a complication of less moment than might be expected, 
provided no primary infection occurs from particles of clothing entering 
the wound, and the wounds of entrance and exit are protected from 
admitting infection from without. Union may occur in bones of the upper 
extremity in three or four weeks, in the femur in four or five weeks, even 
if comminution is extensive. Indeed union may occur more rapidly than 
in non-comminuted fractures by indirect violence in which periosteum 
is stripped up from the bone at the seat of break. 

Primary hemorrhage, due to the fracturing missile, may be serious 
from injury to large vessels. The present opinion appears to be that 




Fig. 907. — ■Uncommi- 
nuted transverse frac- 
ture. 

hard structures. 




Fig. 908. — Butterfly 
fracture. 



T2± 



TREATISE OX FRACTURES 




attempts on the part of the soldier himself or non-medical attendants to 
apply constrictive apparatus to stop hemorrhage is unwise. The danger 
of unnecessarily severe pressure causing distal gangrene is great. This 
is seen also in civil practice from tourniquets and constriction with rubber 

or cotton bandaging for open 
fractures and other wounds 
complicated by bleeding. It 
would be well if non-medical 
attendants giving first aid re- 
membered that stopping bleed- 
ing from a blood-vessel is 
usually as easy as stopping 
water escaping from a punc- 
tured hose. Slight continuous 
pressure with the finger or a pad 
on the opening, or broad circu- 
lar constriction of moderate 
amount with any bandage-like 
material about three inches wide 
is usually sufficient. Gangrene 
from unwise pressure to stop 
bleeding often occurs in open 
comminuted fractures due to 
gunshot or industrial accidents. 
Amputation would often be less 
extensive, or avoidable, if such 
pressure were omitted. 

In gunshot wounds, civil 
and military, tetanus is a 
not uncommon complication. 
Trench fighting and soiled 
hands make infection from its 
anaerobic bacillus in the ground 
an easy matter. Immediate 
The buiiet is treatment with full doses of 
anti-tetanus serum is a wise 
precaution. Small pistols used by boys for celebrating holidays have been 
accountable for many deaths from tetanus in America. Sailors' open frac- 
tures are said to be less frequently infected than soldiers'. The less tend- 
ency to be contaminated with soil and by filthy contacts is evidently the 
reason for sailors' immunity. 

The complication which gives rise to the commanding importance of 
open fractures is infection with pyogenic bacteria. The direct traumatism 
can. sing the fracture often carries contamination into the wound of over- 
lying soft parts and not infrequently into the very marrow and canal of the 



Fig. 



909. — -Gunshot fracture of the tibia, 
lodged in the bone. 



INDUSTRIAL AND AVAR FRACTURES 



725 



bone. Pieces of clothing and fragments of shell have been found even 
jammed into the medullary canal of a long bone broken by a missile 
in warfare. 

Joseph A. Blake states that fractures: (a) caused by rifle bullets 
usually may be considered as not infected, provided that the wounds of 
entrance and exit are both small; (b) those due to wounds with shrapnel 
balls may be looked upon as instances of probable non-infection, when the 
orifices are small, but that the question is not so easily settled as in rifle 
bullet fractures; when there 
is doubt, it is the part of wis- 
dom to regard shrapnel frac- 
tures as infected; (c) frac- 
tures from shell, bomb, or 
grenade fragments must all 
be deemed contaminated with 
infectious material and must 
be treated accordingly. 

A possible contamination 
of the soft parts overlying 
the broken bones is always 
productive of anxiety on the 
part of the surgeon in treat- 
ing open fractures. Gunshot 
fractures derive their special 
importance because the de- 
fensive armor, provided by 
the skin, has been impaired 
by its perforation. Not only 
has the skin been opened by a 
wound but the missile has 
penetrated deeper to the bone 
itself and laid open its medul- 
lary spaces and perhaps car- 
ried contaminating bacteria 
into its central canal through 
a small orifice. The absorp- 
tive powers of the organic tissues of the bone are given full opportunity 
to take up microbic products by reason of fracture surfaces having no pro- 
tective covering of periosteum. The marrow in its tubular canal is shut 
off from efficient external drainage. 

Acute osteomyelitis varying in degree with the relative amount of in- 
fection is the result. The better drainage of comminuted fractures causes 
less danger to arise than in small perforations of the medullary canal of 
tubular bones. Fissured fractures, if infected, may become serious on 
account of defective exit for drainage of infective products. 




Fig. 910. — Aeroplane bracket splint for holding arm m 

abduction and forearm in extension, used in infected open 

fracture of humerus with much loss of bone. (Courtesy of 

Dr. R. B. Osgood.) 



726 



TEEATISE OX FRACTURES 



Infection causes delayed union, necrosis, scar tissue, abscesses, sinuses, 
irregular cavities about sequesters walled in by masses of callus, stiff 
muscles, and ankylosis of joints. 

Infection of the wound occurs in the majority of gunshot fractures 
in civil life. This is said to be unusual in military life, where small jacketed 
bullets of high velocity are used. First-aid aseptic dressings are often 
used by the wounded themselves in time of war. Infection is due to the 
septic missile, the introduction of foreign bodies with the bullet, such 

as portions of the clothing, or is carried in 
from the skin. Sometimes fissures in bones 
made by direct injury may by reason of 
elasticity snap shut and enclose hairs, particles 
of clothes or of soil, and thus give entrance to 
infecting germs. Mere cracks in bones may 
become in this way more serious than extensive 
fractures. On occasion a fissure may run from 
the shaft into the epiphysis and enter the in- 
terior of a joint; thus may arise a septic 
arthritis. This secondary arthritis may 
threaten life and finally necessitate amputation. 
The conduct of an epiphyseal fracture 
from a penetrating missile, like a bullet or a 
fragment from a blasting operation, is dif- 
ferent from what is to be expected in a shaft 
fracture. The fracture, though infected, has 
occurred in bone of a cancellous nature and 
without a canal with compact bony walls. Ex- 
tensive osteomyelitis is not likely to arise ; but 
the bacterial contamination will cause probably 
only a localized osteomyelitis. This may be 
troublesome to cure and be the origin of a 
protracted suppurative process causing local 
abscesses and centres of necrosis. 

Sometimes from this obstinate osteomye- 
litis a fatty degenerative process occurs and the 
epiphysis softens. Blake warns against mis- 
taking this softening for necrosis, which may, as infection subsides, be- 
come hard bone. He states that the entire epiphysis may after this softening 
stage become hard and resume its ability for function. To scrape away 
the soft fatty bone is a serious error. Death is common in infected shot 
fractures from osteomyelitis. Especially is this true in the pulpified frac- 
tures due to large shot, shell fragments and shrapnel. Exposure after 
injury, delay in first aid, careless and ignorant dressing, and hasty operative 
treatment add to the fatalities in war times. Infected fractures of the 
shaft not only unite slowly but necrosis, involving the fragments, 




Fig. 911. — "Aeroplane" bracket 
splint to hold arm in abduction and 
forearm flexed in infected fractures of 
humerus, or of forearm or elbow in- 
jury. (Courtesy of Dr. R. B. Osgood.) 



INDUSTRIAL AND WAR FRACTURES 727 

often occurs. Some of the smaller splinters, especially those deprived 
of periosteum, die, and even large pieces or the ends of the main frag- 
ments may become necrotic. Nature's attempt to detach and expel the 
dead pieces gives rise to much callus. This surrounds the fragments in an 
endeavor to reconstruct the shaft. If the dead portion is superficial or 
not too large, it finally escapes toward the skin. Otherwise it may be 
enclosed in a bony prism ; through the walls of which cloacae allow pus to 
escape and the surgeon's probe to enter. The overlying soft parts are 
swollen with exudate distended by abscess pockets, riddled with sinuses, 
and thickened, hardened, and distorted by contracting scar tissue. The 
bone itself is increased in bulk by irregular masses of ossified callus, 
forming sheaths called involucre, around the dead pieces entrapped in 
cavities with suppurating linings. Cure requires the removal of these 
shut-in sequesters by operation. 

Small pointed bullets, by causing small entrance wounds, the relatively 




Fig. 912. — Gypsum encasement with basket braces of wire and gypsum-gauze tor immobilization of 

infected open and comminuted fractures, in which the knee is to be kept extended. Used for fractures 

of femur or of tibia and fibula. (Courtesy of Dr. R. B. Osgood.) 

less danger of infection and less movement of fragment of clothing within 
the tissues, and the adoption of antiseptic and aseptic methods of treat- 
ment have led to less morbidity, a lowered mortality and better end results 
in gunshot wounds of bone. Such rifle wounds often heal with little 
or no sepsis, and, though markedly comminuted, may be expected to act 
like closed fractures. The result, however, is quite different in deflected 
and soft-nose bullet wounds of bone and in fractures from shell and 
similar projectiles. These often are followed by infection with local 
phlegmons and other septic and pysemic results. A fracture which 
destroys the integrity of the nutrient medullary artery of a long bone 
may be the cause of necrosis and non-union, though it be otherwise an 
injury of no great degree of seriousness. 

Gunshot fractures involving joints are particularly important ; second- 
ary septic arthritis involving risk to joint function may arise, and death 
occur from absorption of toxic products. It is important that conserva- 
tion of motion in a joint be thought of in fractures near the articulation, 
even if the lines of fracture do not enter the synovial cavity. Stiffened 
shoulders, elbows, wrists, and ankles are crippling conditions, the result 



728 



TREATISE ON FRACTURES 



of such traumatisms. It is important, therefore, in fracture surgery of 
gunshots to avoid ankylosis, even if only a temporary fibrous one, by 
watching and dressing the limbs frequently. In shoulders, as a rule, 
abduction of the humerus with deliberate attention to motion at the joint 
will do much to preserve the integrity of shoulder movements. Abduction 
there is better than adduction, if ankylosis occurs. Elbows should be 
dressed, if stiffening is probable, at an angle less than right angle. Frac- 
tures near the hip-joint should as a rule be treated with some abduction 
and in extension since permanent adduction and flexion prevent good 
function. In the knee, when ankylosis is complete from synostosis, a 
lightly flexed posture is the most satisfactory. If some motion is expected 
to be obtained, permanent hyperextension of the joint is more satisfactory 

than partial flexion; since the motion 
when allowed becomes increasingly pain- 
ful and leads to chronic articular changes. 
The ankle should always be flexed at a 
right angle if stiffness is expected. It 
should be remembered, however, that 
women who wear high-heeled shoes do 
better with the ankle slightly extended. 
These deleterious stiffnesses may be 
avoided or lessened in crippling effect by 
massage and early mobilization. This 
should be remembered and fixation ap- 
pliances permitting access to the surface 
of the limb for such manipulation be 
given preference. 

Prognosis. — Unless complications of 
a grave character occur, the prognosis as 
to life is good. Union usually is slow, 
and there is a large mass of callus found 
where there are many fragments. Consolidation requires a long time, if 
there be infection. Cure may be accompanied by shortening, some angula- 
tion of fragments, and persistent sinuses with necrosis of structure. These 
incidents depend largely upon the occurrence of infection or of unrelieved 
muscular displacement from spasm. Non-union is rare unless occurring 
after unwise resection of fracture ends or induced by prolonged infection. 
Flail joints may be produced by injudicious removal of large amounts of 
bone. Even in infected fractures, with great comminution and the 
production of cavities surrounding imprisoned necrotic pieces, union 
is to be expected if the involucre is properly opened, the dead portions 
removed, and fixation continued. The ensheathing callus will unite 
and give a fair result if the fragments have been kept in a relatively 
good position. 

Treatment. — Transportation to a casualty station, a medical relief 




Fig. 913. — Tibia and fibula, tipper extremi- 
ties of right. Gunshot fracture of the tibia. 
A battered conoidal ball impacted. The 
ball struck a little below the tubercle of the 
tibia on the fibular side, where it is seen 
imbedded. Vertical lines of fracture pass 
down the fibular side of the shaft. Inter- 
mediate amputation at lower third of thigh. 
(Mutter Museum, Xo. 1442.01.) 



INDUSTRIAL AND WAR FRACTURES 



729 



building, or a hospital usually claims attention, before institution of 
formal surgical treatment of the fracture itself, whether it be due to war 
projectiles or be received in industrial accident. The clothing should be 
cut away or carefully removed, so as to expose the injured part of trunk 
or limbs. Any gunshot opening or other external wound should then be 
covered with a dry sterile dressing or a clean pad of linen or muslin, 
dampened with alcohol, tincture of iodine, or strong solution of table salt. 
Then a rigid emergency appliance should be adjusted to the limb or trunk 
to prevent motion. If facilities are present, the wound and skin about it 
should be painted with tincture of iodine, alcohol, ether, benzine, or similar 
antiseptic. Water usually does harm, unless it is used under surgical 
supervision. Dryness is a great safeguard against infection from without. 
The drying blood is a better substance to be in contact with the wound 




Fig. 914. — Basket plastic splint with steel bones arranged for immobilization with extended knee and 
some traction on fracture. Applied to infected comminuted fracture of bones of leg. (Courtesy of 

Dr. R. B. Osgood.) 

than any wet application likely to be in the hands of the bystanders. 
Traction is, during the transport, an important adjuvant to the rigid 
splint or stiff protection used to enforce local immobility. In the treatment 
of gunshot fractures the civil surgeon may proceed on the supposition 
that the wound of the soft parts is not infected. During transportation, 
especially in fractures in the extremities, traction is an important 
element of the temporary protection of the broken bone. Without it, 
rigidity of the support, often necessarily applied hastily, is not likely to 
prevent additional laceration of soft tissues by ends of fragments, 
overlapping of fragments with stripping up of periosteum, or some 
degree of angulation. 

If the distance of transportation is great, as it may be in war, the 
splint should be not bulky or heavy, applicable for easy and rapid adjust- 
ment to the patient, allow access to the wound for a possible change of 
the dressing during transit. It also should be an appliance tending to 



730 TREATISE OX FRACTURES 

produce and surely maintain such reduction and alignment of the frag- 
ments as is obtainable in the sudden emergency of accident or battle. 

When the patient has been brought to the spot where formal surgical 
help is procurable, the doctor should see that the part is shaved and the 
skin thoroughly scrubbed with gauze or a brush, using soap and water, 
followed by alcohol, ether or benzine. If there is a wound of exit, the 
track of the bullet should be irrigated with official tincture of 
iodine, a dry sterile dressing applied, the fracture reduced, and 
the part immobilized in a gypsum case. The wound should never 
be explored unless there is considerable hemorrhage or evidence 
of injury to important nerve structures: in which case the wound of en- 
trance should be enlarged, after irrigation with tincture of iodine, all 
bleeding controlled with ligature, and tendons and nerves sutured with 
silk. If drainage is considered advisable, it should consist of folded 
rubber tissue, and under no consideration should gauze be used, as it 
simply acts as a plug, prevents drainage, and spreads infection. Ampu- 
tation is seldom required in gunshot fractures in civil life. When disin- 
fection of the wounded surface or the bullet track has been effected, the 
wound or wounds dressed, and replacement of fragments accomplished, 
rigidity to the broken bone should be given by retentive appliances as in 
ordinary fractures, closed, open, or infected. 

LaGarde truly says that gunshot injuries are not a special department 
of surgery, but may be met by the civilian surgeon as well as his military 
colleague under similar circumstances, since the weapons used by the 
sportsman closely resemble those of the soldier. The open fractures of 
Avar, however, show more injury to the soft parts, more breaking up of 
bone, more inclusion of foreign bodies in the wound, and greater impair- 
ment of vitality of tissues from molecular concussion. 

While it is true that rifle wounds differ from those received from 
artillery, and that men fighting in trenches are more subject to contamina- 
tion from necessarily filthy habits and contact with the earth (perhaps 
under manurial cultivation for years), the underlying surgical principles 
involved are the same as those of industrial and other accidental injuries 
to bone. Some of the differences in the present war, recorded by surgical 
officers, may undoubtedly be attributed to the circumstance that the young 
surgeon of the twentieth century has gained his experience almost exclu- 
sively in what ma}- be called Listerian surgery. The survivors of the old 
regime will doubtless recognize and understand, perhaps to the profit of 
their soldier patients, the necessity for drainage by gravity, frequent and 
copious dressings, and abundant irrigation in the treatment of the foul 
wounds and fractures now met on the firing line and at the base hospital. 

Xon-contaminated fractures should be managed by the prompt appli- 
cation of the first-aid dressing of the soldier and no attempt should be 
made to investigate the wound of entrance or exit with finger or probe. 
Fixation by some external immobilizing dressing should be used and trans- 



INDUSTRIAL AND WAR FRACTURES 731 

portation provided as promptly as possible. The upper extremity may 
usually be immobilized temporarily by using the thorax for support. The 
lower extremity may often be similarly steadied by using the opposite leg 
as a splint. These methods of temporary character apply to both military 
and non-military accidents. Foreign bodies driven into the wound by the 
projectile should not be searched for on the firing line nor at the seat of 
accident, but allowed to remain until suitable time and care can be given 
to the study of the injury, and suitable fixation apparatus and definite 
treatment made available. 

Delorme, speaking of the expediency of extracting a metallic foreign 
body, holds that those causing neither uneasiness nor pain should as a rule 
be let alone particularly at the beginning of treatment, because extraction 
may greatly protract operation. If, however, it is badly tolerated or lies 
in contact with vessels or nerves or is situated in a focus of suppuration, 
it should be removed. A bullet that is discovered lying beneath the skin 
may be taken out, if aseptic precautions may be obtained. 

A shell fragment that is large, irregular and sharp, and also a shrapnel 
bullet, according to Delorme, must always be removed shortly after the 
injury. This in war should be done in a permanent shelter either at the 
front or in the rear of the fighting line. His reason given for this peremp- 
tory rule is that shrapnel wounds are so frequently complicated by foreign 
bodies carried in from the clothing. After removal of the metal the 
bottom of the wound should be methodically explored for materials car- 
ried in by the missile. 

It will be seen by these statements that there is a distinct difference 
between the aseptic open fractures caused by small-calibre encased bullets 
and those due to hardened shrapnel bullets or irregular pieces of metal. 
The latter are accompanied by much more laceration and are pretty sure 
to be infected, as are wounds received from any sort of projectiles obtained 
during trench life. 

The danger comes from the septic contamination giving rise, in pulpi- 
fied and comminuted bone, to an infectious osteomyelitis, which overshad- 
ows the loss of continuity and rigidity in the bone. After a patient with a 
gunshot wound has been transported to a base hospital, or brought out of 
the woods where he has been hunting, to a fairly equipped modern hos- 
pital, the problem is the same. The temporary immobilization is to be 
substituted by reduction, which previously need not be insisted upon, and 
by permanent immobilization. 

In non-infected gunshot fractures, the treatment is practically the 
same as in ordinary subcutaneous fractures or open fractures which have 
been preserved from becoming infected. 

In infected fractures, comminuted or otherwise complicated, the treat- 
ment is the same whether the injury be received in military, industrial, or 
non-military life. 

In the severe open comminuted fractures with crushed tissues which 



732 TREATISE ON FRACTURES 

above have been called " infected pulpified fractures," the treatment is 
the same for a man brought from filthy trenches with crushed limbs as 
it is for a man who has been wounded by a railroad train, a machinery 
crush, or the explosion of nitroglycerin or other such agents of mod- 
ern industry. 

These observations mean that early in the case occlusion of wounds 
to prevent infection, the use of tetanus antitoxin, prompt and efficient 
morphia administration and the use of remedies for shock are essential. 
At first, temporary immobilization with any rigid material or with gypsum 
gauze splints, if there be time and conveniences, and careful transportation 
are required. Later, ordinary surgical principles combined with experi- 
ence in the treatment of desperate infections will meet the indications of 
those cases in which are met the burrowing abscesses, the absorption of 
pyogenic toxins, and the other results of septic or true pysemic infection. 

Ritschl has formulated a number of valuable rules for German mili- 
tary surgeons which deserve wide circulation and observance. Some of 
them may be thus paraphrased : 

Remember that immobilization of joints may cause stiffness and 
disuse of muscles, weakness and atrophy. 

In severe fractures, early mechano-therapy will save time, trouble, 
and money. Try by wise treatment to avoid the need of orthopaedic 
after-treatment. 

Do not keep joints near to, or involved in, the fracture in a single 
position. Changes in the angle of the joint are wise. Passive motions 
are important. 

Very early resort to massage, electricity and active movements, both 
with and without resistance, are valuable, if used under the surgeon's 
supervision. These agencies may preserve muscular functions. 

The extensor muscles atrophy more rapidly than the flexors. Above 
all things prevent disability of the power of the deltoid of the arm and 
the four-headed extensor of the thigh. 

If on account of severe injury to soft parts prolonged immobilization 
becomes necessary, place the joints in a position in which, if ankylosed, 
they will be most useful : 

Shoulder : In the position afforded by an ordinary sling. 

Elbow : At a right angle. 

Forearm : In pronation. 

Wrist : Over-extended as in writing, or as in clenching the fist. 

Fingers : Slightly flexed. 

Hip : Slightly flexed and abducted. 

Knee : Slightly flexed. 

Ankle : About at right angles and slightly rotated- inward. 

Avoid allowing the wrist to fall into continued flexion when the arm 
is carried in a sling, since if permanent, tight closure of the fingers 
is prevented. 



INDUSTRIAL AND WAR FRACTURES 733 

Keep fingers limber. Don't overbandage them and don't forget to tell 
the patient to keep them in motion. 

The " lymph lavage " of Almroth Wright with hypertonic solution 
of 0.5 per cent, sodium citrate and 5 per cent, solution of salt, as a cleanser 
of wounds, and the coincident use of vaccine treatment may perhaps equal 
or exceed the value of the older methods of treating virulent bone infec- 
tions. Antiseptic solution, powders, and oils now being employed by 
Cheyne, Carrel, and others are probably more effective. 

A definite operative technic for trimming aw T ay devitalized soft tissues 
and bone fragments which threaten to harbor infective germs has been 
developed during the later months of the European War. By thus cutting 
out the contaminated structures, before sufficient time has elapsed to per- 
mit sapraemic or septic developments, immediate or primary closure of 
the wound at the seat of fracture may be performed. Union may thus 
be secured and the fracture become a closed one, capable of healing 
with union of the fragments without local inflammation or toxic gen- 
eral symptoms. 

Amputations and joint resections would doubtless be rare in gunshot 
fractures if the injured could have immediate attention at the hands of 
experienced surgeons and be given transportation of a proper kind and 
efficient after-treatment. The prevention of these lamentable opera- 
tive mutilations lies with great frequency in the prompt adoption, for 
fractures from war projectiles, of a complete and methodical intervention 
to remove contaminated tissues before infection has had time to develop. 
Alquier and Tanton, Leriche, Blake, and other military authorities give 
strong testimony on this point. The aim of this " debridement " or 
trimming away, which is associated with extraction of embedded foreign 
bodies, is prophylaxis. It, if done within say 8 or 10 hours, may enable 
the surgeon to close the projectile's wound in soft structures and bone, 
and convert, by primary suture, a contaminated and otherwise compli- 
cated fracture into a closed fracture. The injury will then go on to cure 
without suppuration and its attendant septic complications. It will need 
only the physiologic and mechanical treatment of a non-contami- 
nated fracture. 

Blake warns against attempts at debridement until the facilities for a 
formal aseptic intervention have been secured unless severe hemorrhage 
forbids this few hours' staying of the surgeon's hands. For hemorrhage, 
clamp forceps should be applied to the bleeding vessels. Circular com- 
pression of a tourniquet or the insertion of a tampon as a plug should 
be avoided. All fractures, except those made with a bullet causing punc- 
tured wounds of entrance and exits, should be subjected to operation. 
The earliest possible moment is best for preventing suppuration, gas 
gangrene, and tetanus. The method in principle is the same for the soft 
parts and the damaged bone, except in certain fractures involving joints. 
These may need some deviation from the routine method. 



734 TREATISE OX FRACTURES 

These are the successive steps : Dry shave the operative area, clean 
surface of wound and skin with ether, paint with 3 to 5 per cent, of iodine 
in alcohol, excise edges of wound, enlarge wound superficially to discover 
and inspect deep recesses, pare away structures with scissors or knife 
until untorn tissues, with healthy color and contractile muscle response, 
are reached. 

During this procedure remove all foreign bodies. These must be 
searched for with great diligence. The use of X-rays may aid in locating 
metallic foreign bodies and splinters of bone. With this as an aid the 
surgeon may be better able to select the best incisions for reaching pieces 
of projectile. It is not really necessary to use staining solutions in the 
wound to indicate devitalized soft tissues by coloring them. A good 
fixing stain is methyl blue, 5 per cent., in 20 per cent, solution of liquor 
formaldehyde. Wounds treated as here indicated may be closed at once 
and the fracture reduced and fixed with apparatus applied outside the 
skin. This primary closure is the ideal to be aimed at in gunshot fracture. 
When, however, there is doubt about the thoroughness of this early 
removal of contamination, primary suture is unwise. It is unwise unless 
the patient is to be retained under observation and not evacuated to 
another hospital. Under either of these circumstances, closure should be 
postponed for two or three days with aseptic or antiseptic precautions, 
and delayed primary suture then adopted. 

If the open fracture becomes infected because time has elapsed for the 
contaminating material to work its evil influence, the surgeon should not 
attempt closure but wait until he can control and eliminate the infection 
by Carrel's instillation of neutral hypochlorite of sodium solution or by 
other antiseptic, and granulation of the wound has occurred. This sec- 
ondary closure, by suturing the wound leading to fracture, may be done 
when the bacteriological control examinations, made daily or every other 
day, show a sterile wound secretion. As a rule, it is well to make a re- 
excision of the tissues before suturing a granulating wound. Otherwise 
there will be much scar tissue produced in the wound with the inevitable 
contraction of this process. 

Contaminated fractures may be handled in this way by primary or 
delayed primary closure. As a rule, however, primary closure is rather 
risky because of the possibility of not thoroughly removing the many 
particles of foreign material scattered among the multitude of small frag- 
ments of a comminuted gunshot fracture. Especially is this the case 
in fracture due to a bullet of high velocity causing an explosive effect 
(Fig. 915). In such injuries, the dispersion through the soft tissues 
spreads the contaminating materials in a cone-like area from the point 
of impact. Free access to the medullary cavity of shaft fractures may 
not be easily gained in the debridement of moderate comminutions, 
or may be neglected in uncomminuted fractures and in penetrat- 
ing fractures. 



INDUSTRIAL AND WAR FRACTURES 



735 



It is usually, therefore, probably wise to resort to delayed primary 
union of the wound accompanying a serious gunshot injury. If primary 
closure is selected, however, as it may be successfully in some gunshot 
wounds of bone, in which the medullary cavity has not been opened, the 
soft parts, after the trimming, should be carefully coapted with inter- 
rupted absorbable sutures, allowing interspaces for leakage, with silk- 
worm gut threads introduced to the bottom of the wound for drainage. 
This drainage is removed in a couple 
of days and the bacteriologic culture 
used to settle the question of the 
aseptic or septic state of the bottom of 
the wound and the region of fracture. 

The treatment must be different, 
when it is evident that the marrow 
canal has been opened by a penetrat- 
ing or perforating missile. The mar- 
row has been in contact with foreign 
material, almost surely carrying in- 
fecting germs. This event requires 
that the medullary canal be opened 
for exploration, removal of contami- 
nating substances and provision for 
drainage or disinfection of the 
exposed bone. It is quite probable 
that this will require a portion of 

the Compact bone tO be CUt away. Fig. 915.— Comminuted fracture caused by a bullet 
Tt, „ ^ 1 '11 1'1 1 at high velocity with explosive effect. 

I he marrow canal will very likely 

require freer opening than can be obtained by merely removing detached 
fragments or partially separated splinters. Portions of bone still attached 
by periosteum may aid in blocking exposure of the shaft's canal. Com- 
pletely detached fragments should be removed. They seldom survive the 
septic processes of these gunshot fractures. 

The operator, when opening the canal, should see to it that his resection 
of bone does not destroy the continuity of the bone. His excision to ex- 
pose the interior of the tube should be in a longitudinal direction and not 
in transverse section. The portion cut out should not be torn off or 
pulled entirely out; a layer of bone should be left attached by a hinge 
of periosteum. This peeling up of a thin sheet of bone with the fibrous 
and the osteogenetic layers of the periosteum still adherent is readily 
done by using a very sharp periosteal elevator (Fig. 916) . This procedure 
insures that the bone itself is cut into by the chisel-like edge of the instru- 
ment. The bone should be attacked if possible through a muscular inter- 
space or at a subcutaneous surface. The thin serrated layer of bone lifted 
with the under surface of the periosteum has bone proliferating properties. 




736 



TREATISE OX FRACTURES 



This is valuable in creating callus for uniting and repairing the fractured 
bone. Loewy speaks of the periosteum thus acting as a graft carrier. 
This retention of periosteum is said to be an essential, especially in frac- 
tures of adults, in whom the periosteum itself has, some believe, little 
ossifying function. It is important to open both sides o<f a bone which 
has been perforated by the missile. 

When the fracture is one not requiring the type of operation just 
described for opening the medullary cavity, because the shattering of 
the shaft has thoroughly opened that canal, fragments may be treated by 
cutting away the infected surface. This is done with sharp periosteal 
separators of various widths used, as in the operation on perforated shafts, 
to lift off periosteum with a thin layer of underlying bone. The bony ele- 




Fig. 916. — Separating the periosteum with the sharp periosteal elevator cutting into the bone. 

ments of contaminated open fractures are in this manner subjected to 
debridement as are the soft structures of the limb. 

The preceding discussion shows why primary closure of the soft parts 
over a gunshot fracture is advisable in only a small proportion of the 
cases. Delayed primary suture is usually better treatment. This is also 
to be considered wiser in fractures of the femur; that bone is deeply 
buried in muscles. Bacteria which grow best without air have a better 
chance to exert their malignant power if lying in a closed wound; hence 
delay in closing fractures may be the method of choice in deeply seated 
fracture as those in the shaft of the femur. Such locations make thorough 
removal of contaminating materials more difficult than in subcutaneous 
bone. This is another reason for selecting delayed primary closure in 
preference to immediate closure of the soft tissues encircling a contami- 
nated fracture in war or civilian practice. 



INDUSTRIAL AND WAR FRACTURES 737 

Operations Upon Infected Fractures 

Trimming the soft tissues, removing splinters of bone and cutting 
away portions of bone likely to become necrotic, with the intention of pri- 
mary closure of the wound over the fracture, is not to be undertaken except 
during the eight or ten hours immediately following injury. The wound 
after that time, and sometimes even earlier, has become infected by the 
contamination. Success with primary closure cannot be expected in 
treating infected wounds. Incisions are to be made to facilitate drainage 
of the septic fluids and inflammatory products; but the tissues, which 
are endeavoring to protect themselves from absorbing bacteria and their 
toxines, must be handled gently. Foreign bodies should be cautiously 
removed and actually dead tissues may be cut away ; but fresh incisions, 
made in structures still living, give avenues of entrance for septic micro- 
organisms by absorption and should be avoided. When such cuts are 
needed to afford drainage by gravity or to remove foreign bodies they 
should be long and left wide open, not packed with gauze or tight drainage 
materials. Digging into the depths of the wound is a very dangerous 
practice. It may open fresh portals for septic absorption. 

In gas bacillus infection the pathological process spreads in muscular 
tissue; at times it is limited by the sheath of the muscle. Incisions should 
in gas -cases be made parallel to the muscle fibres. The cuts should t be- 
very free and the surgeon should remove all the dead muscular structure. 
An entire muscle may have to be cut out to stop the spreading of the 
gaseous necrosis of that tissue. The knife should be used until living 
and therefore bleeding muscle is uncovered. In infected fractures it is 
well not to resect the ends of the bone or to remove attached fragment. 
It is better practice to wait till necrosis has taken place or the sequester has 
been pretty well surrounded with the involucre or bony sheath. Free 
drainage, gauze drains lightly placed in the open ways, and Carrel instilla- 
tion with neutral sodium hypochlorite is, according to Blake, a useful 
routine method. The gauze drains may be left in place until they 
become loosened. The wounds must not be plugged. Drainage tubes 
are not satisfactory. 

Cleansing may be done by using, on the wound and surrounding 
skin, soap and water, weak formaldehyde solution and soap suds ; or, if the 
wounds are wide open, solution of hydrogen peroxide may be applied and 
followed by alcohol or ether. The infected fracture should not be closed 
until it has become sterile, or relatively sterile. 

It is seldom that gunshot fractures of the shaft should be subjected to 
formal excision operations. This taking away of all the broken-up 
bone is not widely useful. Only an atypical removal of bone, such as is 
sufficient to open freely the infected marrow cavity, is to be recommended 
as a routine. This rule does not apply, however, to gunshot fractures 
of severity of the joints. Here excision may quite often be required. In 
47 



738 TKEATISE ON FRACTURES 

these operative procedures care must be used to preserve the periosteum 
in what Blake calls a continuous sheet. The elevator should be very 
sharp and cut away a thin layer of bone with the overlying perios- 
teum. This is very especially important where the muscles are attached 
to the periosteum. The cartilage should be removed from the articular 
surfaces, usually of both bones comprising the joints. The periosteum 
is thus left as a fibrous tube with an osteogenetic layer of bone lining it. 
The periosteal tube remaining is to be lightly packed with gauze so as to 
prevent its walls collapsing. This is replaced at rather long intervals. 
Drainage may at times be required in addition to the loose gauze packing. 

The intention is to keep the resected ends of bone separated until infec- 
tion has been controlled. This is the purpose of the treatment even if 
ankylosis is believed certain to occur, or is a desired outcome as in the 
knee-joint resections. Gunshot fractures of joints should be subjected 
to early active and passive motion. This is important also in resections. 
Removal of the cartilages is important in infected joint fractures. Failure 
to get rid of this structure serves to prolong the suppuration. 

Internal fixation with metal bands or plates has been strongly con- 
demned in gunshot fractures. It is said to be unwise, especially in in- 
fected fractures. Even the greatest advocates of direct fixation in civil 
surgery have been inclined to abstain from its employment in open 
infected fractures met with in civilian hospitals. 

Infected open fractures seen in war and in industrial surgery often 
unite with dead bone in the callus; from which sinuses run to the skin 
surface. Out of these there are continuous or intermittent escapes of 
pus; often abscesses in the deep structures occur, requiring surgical 
incisions. These results of chronic infection may continue for months 
or years until the enclosed sequester escapes or is removed by surgical 
means. These dead pieces of bone cause chronic osteitis and excessive 
development of callus. It is at times rather difficult to decide when is 
the proper moment in which to operate, with chisel or electric saw or 
burr, for the purpose of lifting out the necrotic pieces. Too early opera- 
tion may so weaken the encasing callus that re fracture of the shaft occurs. 
Establishing the cure through stopping suppuration and getting a firm 
bone without sinuses probably relieves the disability and returns the 
soldier or the workman to duty. Delay is therefore to be avoided. Six 
weeks, perhaps, is an average period to postpone operative attack. Radio- 
graphic examinations and the use of the probe thrust along the sinuses 
will aid a good deal in determining when to operate. Stereoscopic plates 
are of especial value in this diagnostic effort. There is seen a clear space 
between the sheath and the dead portion of bone. The necrotic portion 
gives a denser shadow than the enveloping sheath of new bone. The' 
usual method is to cut out the scar of an old cloaca or follow the track of a 
still discharging one until the opening into the mass of callus is disclosed. 
The periosteum, often much thickened, then is to be carefully lifted up and 



INDUSTRIAL AND WAR FRACTURES 739 

search made for the white sequester. This is to be lifted out; and the 
wound sterilized and later closed. Primary closure cannot often be 
obtained. Sometimes, however, scraping the walls of the cavity in which 
the dead bone lay and using strong antiseptics on the rawed bony bed 
may be followed by rapid union of the overlying soft parts. Flaps of 
skin may be turned down into the cavity. The cavity may be allowed 
to fill up with blood-clot or Moorhof-Mosetig antiseptic wax may be used 
as a filler of the hollow in the bone before suturing the enveloping 
muscles and integument. Sometimes the periosteum may be allowed 
to fall into the deep groove resulting from the sequestrotomy. 

Should the medullary canal at the ends of the main fragments become 
plugged with new bone, union may not be obtainable unless the canal is 
opened in both fragments by sawing off these dense ends. Bone-grafting 
may be found useful in such cases by enabling the operator to prevent the 
shortening due to such extensive excision of the extremities of the frag- 
ments. Inlay bone grafts are valuable in such cases, and also in non- 
union with atrophy of the ends of fragments with closure of the marrow 
canal. Fixation plates may be serviceable, when there is loss of substance 
from the original injury or from operation by excision. In bone-grafting 
operations one needs contact between sawed surfaces of bone; and if 
possible with widely open marrow canals. 

When actual non-union has not yet occurred, but there is delay in 
union, use of the limb, general hygienic treatment, passive congestion by 
means of the rubber bandage proximal to the fracture, lime salts for 
internal medication, massage, and focal stimulation with electricity are 
acceptable adjuvants to the maintenance of alignment with gypsum encase- 
ments or other rigid external splints. 

The foregoing statements regarding treatment of gunshot fractures 
apply with much force to fractures received in industrial life. Those 
surgeons who have care of the employees of factories, mines, railroads, 
shipyards, building operations, and civil engineering projects will do well to 
follow the indications of transport, treatment, and reconstruction taught 
by military experience. The manual of splints and apparatus for the 
Medical Department of the United States Army should be in the hands of 
every such surgeon and in the library of every civilian hospital. 



INDEX 



Acetabulum, fractures of, 490 

Adhesive plaster dressing for maintaining 

Jones' position, 376, 378 
Albee, F. H., method in the treatment of 
fractures, 124 
instruments used. 125 
technic of using inlay bone grafts in 

fresh fractures, 126 
technic of using inlay bone graft in 
ununited fractures, 126 
Albee's method of bone inlay in treatment 
of non-impacted fractures of the neck of 
the femur, 530 
Allis's method of determining shortening in 

fracture of neck of femur, 510 
Ambulatory treatment of fractures, 86 
advantages, 86 
disadvantages, 86 
American Surgical Association, quoted; 
conclusions in the operative treatment of 
fractures, 46, 128, 129 
Anaesthesia in the reduction of fragments, 

59 - • A 

cocaine, novocame, 04 

ether, 64 

nitrous oxide gas and oxygen, 64 

Anaesthesia in reduction of elbow fractures, 

374 
Anaesthesia in reduction of fractures at 

lower end of radius, 450 
Ankylosis, secondary, following fractures of 

lower end of humerus, 375 
Arteries and veins, injury to, in fractures, 29 
Artery, middle meningeal, 142 
Artery and vein, popliteal, injury to, in frac- 
tures of lower end of femur, 577 
Ashhurst, A. P. C, quoted ; end-results in 
fractures of lower end of humerus, 383 
Ashhurst, A. P. C, quoted ; nerve, median 
injury in fractures of lower end of 
humerus, 374 
Asphyxia, traumatic, 282 
Astragalus, 667 
etiology, 668 
prognosis, 669 
results, 671 
symptoms, 669 
treatment, 670 
varieties, 668 

Balanced suspension in fractures, 94 
Balcan frame in fractures of femur, 563 
Bardenheuer's method of extension, 77 

principles involved, 78 

advantages, 79 

disadvantages, 78 
Barton's fracture, 434 
Barton's, reversed fracture, 435 
Battle, quoted ; mortality of skull fractures, 

177 
Beds, fracture, 63 



Bennett's fracture, 469 

Bergmann, quoted ; cerebrospinal fluid, 

amount, in basal fractures, 164 
Bergmann, quoted; hypoglossal and spinal 
accessory nerves, injury in basal frac- 
tures, 167 
Bergmann, quoted; eye changes in middle 

meningeal hemorrhage, 169 
Bergmann, quoted ; mortality of skull frac- 
tures, 178 
Bergmann, quoted ; operative mortality in 

middle meningeal hemorrhage, 189 
Bladder and urethra, rupture of, in frac- 
tures of pelvis, symptoms of, 498 
Bladder and urethra, injury to, in fractures 

of pelvis, 499 
Blake, quoted ; operative mortality in middle 

meningeal hemorrhage, 189 
Birth fractures, 704 
cranium, 704 
etiology, 704 
symptoms, 705 
treatment, 705 
clavicle, 708 
etiology, 708 
treatment, 708 
femur, 709 
etiology, 709 
symptoms, 709 
treatment, 712 
humerus, 706 
deformity, 706 
etiology, 706 
symptoms, 706 
treatment, 707 
skull, 704 
etiology, 704 
symptoms, 705 
treatment, 705 
operative, 705 
Bone grafts, Albee, 124 
Bone grafts, Walsh, 118 
Bone grafts, inlay, 126 
Bradford frame, in treatment of fractures 

of femur, 585 
British Medical Association, statistics of in- 
dividual fractures as reported by commit- 
tee of, showing results of operative and 
non-operative treatment, 102 
British Medical Association, fracture com- 
mittee, quoted ; cause of failure in opera- 
tive treatment, 104 
British Medical Association, committee on 
fractures, quoted ; results in the treatment 
of fractures of the shaft of the femur, 568 
British Medical Associaton, committee on 

fractures, quoted, 102 
British Medical Association, committee on 
fractures, quoted ; results in the treatment 
of fractures of the tibia and fibula, 637 

741 



742 



INDEX 



Broca and Mouchet, quoted; nerve injury 
in fractures of lower end of humerus, 374 

Brown-Sequard, paralysis, in vertebral frac- 
tures, 262 

Bruns, quoted ; results produced by pistol 
bullet, 155 

Bruns, quoted; statistics, failure of union 
following fractures of humerus, 349 

Bruns, quoted; nerve injuries complicating 
fractures, 342 
musculospiral, 343 
ulnar, 343 

Bryant's vertical extension, 78 

Bryant's triangle, in determining fractures 
of the neck of the femur, 510 

Buck's extension, yy 

Buck's extensions in fractures of neck of 
femur, 537 

Burkhard, quoted; mortality of skull frac- 
tures, 178 

Burnham, A. C, quoted; mortality in skull 
fractures, 179 

Calcaneum, 671 
etiology, 672 
prognosis, 682 
statistics, 678 
symptoms, 680 
treatment, 682 
non-operative, 682 
operative, 683 
varieties, 672 
Cardiovascular changes, in fractures, 42 
Carpal bones, 462 
anatomy, 462 
diagnosis, 465 
etiology, 463 
statistics, 463 
surface markings, 463 
symptoms, 464 
cuneiform, 465 
scaphoid, 464 
semilunar, 465 
treatment, 466 
Carrying angle, 383 
Carrel-Dakin, hypochlorite solution, 91 
Cartilages, costal fractures of, 276 
Cerebrospinal fluid, amount, in basal skull 

fractures, Bergmann, quoted, 164 
Cerebrospinal fluid, amount of. in skull 
(basal) fractures, MacCormac, Sir W., 
quoted, 164 
Cerebrospinal fluid in skull (basal) frac- 
tures, Phelps quoted, 164 
Rawling quoted, 164 
Chauffeurs' fracture, 437 
Chipault, quoted; operative mortality in 

vertebral fractures, 245 
Causes, 2 

predisposing, 2 
exciting, 3 

by external violence, 3 
muscular action, 3 
Clavicle, 286 

anatomy, 286 
complications, 295 
diagnosis, 292 



Clavicle, etiology, 287 
prognosis, 295 
varieties, 290, 708 
surface markings, 286 
symptoms, 298 
inner third, 293 
middle third, 290 
outer third, 293 
treatment, 295, 708 

claviculo-humeral dressing, 300 
dorsal recumbency, 296 
operative, 301 
reduction in children, 295 
reduction in adults, 296 
Sayre dressing, 298 
summary of, 302 
Closed fractures, wiring of, 101 
treatment of, 61, 704 
treatment of, operative, 97 
Coccyx, fractures of, 493 
Codivilla's method of nail extension, 80 
Coenen, quoted; nerve musculospiral injury 
in fractures of lower end of humerus, 374 
Coler, quoted ; explosive action upon brain 

by bullet, 155 
Colles's fracture, 429 
Colles's fracture, reversed,-429 
Coma in head injuries, differential diagnosis 
from other forms of unconsciousness, 175 
Comminuted fractures, 11 
Complications of fractures, 29 

arteries and veins, injury to, 29 
cardiovascular, 42 
delirium, alcoholic, 40 
delirium, traumatic. 40 
dislocation, association of a, 36 
embolism, fat, 2>7 
infection, 38 
joints, injury to, 35 
lesions of soft parts, 29 
muscles, injury to, 32 
nerves, injury to, 31 
pulmonic, 41 

shock and hemorrhage, 40 
thrombosis and embolism, 38 
Compression fractures, 11 
Concussion, cerebral, 171 
etiology of, 171 
symptoms of. 171 
Contraindications to operative treatment in 
closed fractures, 99 
those due to the fracture, 99 
those dependent upon the patient's gen- 
eral condition, 99 
those pertaining to the operator, 99 
those relating to the environment, 99 
Contracture, Volkmann's, S3, 35, 371 
Contusion, cerebral, 173 
location of, 173 
symptoms of. 173 
Costal cartilages, 276, 285 
Cortor's, F.. method of operative impaction 
of fragments in intercondylar fractures of 
femur, 574 
Cotton's method of palpation of anterior 
surface of bodies of cervical vertebrae, 236 



INDEX 



743 



Cotton's method of operative impaction in 
treatment of non-impacted fractures of 
neck of femur, 530 
Cotton's method of operative reduction of 

fractures of the calcaneum, 683 
Coxa vara, traumatic, 533 
Crandon and Wilson, quoted; hemorrhage 

and mortality in basal fractures, 163 
Crandon and Wilson, quoted ; cerebrospinal 

fluid in basal fractures, 164 
Crandon and Wilson, quoted ; mortality of 

skull fractures, 177 
Craniocerebral localization, 141 
Cranium, 139 
Cranium, anatomy of, 139 
Cranium, fractures of, 139 
causes of, 147 
cerebral concussion in, 171 
cerebral contusion in, 173 
decompression, 182 
diagnosis of, 174 
differential diagnosis, 175 
fractures of base of, 156, 186 
of base, symptoms of, 162 
of, injuries to brain, 171 
of intracranial hemorrhage in, 167, 

186 
lumbar puncture, 182 

of, by Contre-Coup, 158 
mechanism of, 157 
mortality, 177 
operations in, 184 
prognosis, 177 
summary of treatment, 194 
treatment, 179 

of trephining in, 184 
trephining, Hudson's method, 185 
trephining, Hopkins' forceps, 190 
trephining, Masland, 184 

Roberts' method, 184 
varieties of, 147 
of vault, 182 
venesection in, 181 
Crepitus in fractures of neck of femur, 522 
Crepitus in fractures, 17 
Cubitus valgus, 383 
Cubitus varus, 383 
Cullen, quoted; optic nerve injury in basal 

fractures, 166 
Cuneiform, fractures of, 465 
Cushing, quoted; location of injury in spinal 

cord lesions, 254 
Cushing, quoted ; in cerebellar decompres- 
sion, 182 
Cryer's method of splinting mandibular 
fractures, 225 

Debridement in war fractures, 90, 728 

Definitions, 1 

Deformities, 16 

Decompression in fractures of skull, 182 

Delatour, quoted; end-results in the opera- 
tive treatment of fractures of the patella, 
601 

Delayed union, 27 

Delirium, alcoholic, in fractures, 40 

Delirium, traumatic, in fractures, 40 



Delorme, quoted ; treatment of imbedded 

particles in gunshot fractures, 731 
Dejerine, quoted; relationship of segments 
of spinal cord and nerve roots to bodies 
and spines of vertebrae, 251 
Destot, Vignard and Barlatier, quoted; 
nerve injury in fractures of lower end of 
humerus, 374 
Diagnosis, 19. See also discussions in vari- 
ous fractures 
differential of injuries about shoulder- 
joint, 335 
in coma, in head injury, 175 
lower end of radius, 448 
Rontgen rays in, 20 
Diaphysis and epiphysis, rules of bony union 

of Gerrish, quoted, 48 
Diastasis, 12, 14, 48. See also epiphyseal 

separations 
Disability, average period of, in subcuta- 
neous fractures as reported by the com- 
mittee of the B. M. A., 46 
Disability following fractures, Estes, W. L., 

quoted, 47 
Diseases, constitutional, in the prevention 

of union, 121 
Dislocation, adjacent, associated with a frac- 
ture, 36, 118 
Dislocation, definition, 1 
Displacement of fragments, 13 
absence of, 15 
etiology of, 15 
varieties of, 14 
Distortion, 1 
Duchain, quoted; operative mortality in 

middle meningeal hemorrhage, 189 
Dwight, quoted ; hemorrhage in basal frac- 
tures, 163 
Dwight, quoted ; hemorrhage from middle 
meningeal in skull fractures, 168 

Ecchymosis, 17 

Eguchi, quoted ; epilepsy, traumatic, fol- 
lowing skull injuries, 179 
Embolism, fat, 2>7 

and thrombosis, 38 
Epiphyses, ossification of, 48 

separation of, 48 

union of, 48 
Epiphyseal separations, traumatic, 48 
Epiphyseal separations, 12, 48 

anatomy, 48 

complications, 58 

date of ossification and time of union 
with diaphysis, 48 

diagnosis of, 58 

etiology, 56 

occurrence, 56 

radiographic findings, 58 

sequelae, 59 

symptoms, 59 

treatment, 59 
Epiphysis, separation of lower radial, 431 
Epilepsy, traumatic, following skull injuries, 

Eguchi, quoted, 179 
Estes, quoted ; statistics showing period of 
disability in open fractures. 47 



7M 



IXDEX 



Etiology of fractures, 2 
exciting causes, 3 
predisposing causes, 2 

Eversion and inversion in fractures of neck 
of femur, 520 

Extension or traction dressings and methods, 
77, 94. 386^ 542 
Bardenheuer's method, 77 
Bryant's method of vertical traction, 79 
Buck's extension, 77 
Lyle's balanced suspension and traction, 

94, 386. 542 
Nathan R. Smith method of traction, 81 
Steinmann's nail extension, 79 
Thomas splint method of traction, 81 
Codivilla's method of nail traction, 80 
Zuppinger's method of traction, 82 

Face, bones of. fractures of, 194 

anatomy, 194 
Fat embolism, ^7 
Femur, fractures of. 505 
anatomy, 505 

methods of determining shortening in 
fractures of neck of femur. 510 
varieties, 515 
surface markings, 508 
upper end, 512 
head, 512 
etiology. 513 
symptoms. 518 
neck, 512 

diagnosis, 518 
diagnosis, differential, 523 
etiology, 513 
prognosis, 524 
symptoms, 518 
treatment. ?2? 

impacted fractures, 517 
non-impacted, 518 
Buck's extension, 526-583 
traction and abduction. 527 
Whitman's abduction. =527. 534 
Ruth-Maxwell, 528 
Cotton's method. 530 
Thomas. 530 
Albee's bone inlay, 530 
nailing, 530 
operative, 586 
after-results, 530 
splints. Smith's anterior, 583, 587 
Bradford frame, 585 
Hodgen, 588 
Lyle's 542 
Thomas. 585 
epiphysis, separation of upper, 531 
diagnosis, 533 
etiology, 532 
symptoms, 532 
treatment, 533 
Whitman's abduction method, 534 
trochanters, through the, 534 
etiology, 536 
lines of fracture. 536 
symptoms, 536 
treatment. 537 

Buck's traction, 537 



Femur, fractures of, 
upper end, 

trochanters, th rough the, 
treatment. Whitman's method of 
abduction, 537 
great trochanter, 537 
etiology. 537 
lines of fracture. 535 
prognosis. 538 
symptoms. 538 
treatment, 538 
lesser trochanter, 538 
etiology. 539 
symptoms, 539 
treatment, 539 
subtrochanteric region, 539 
etiology. 540 
prognosis. 541 
symptoms. 540 
treatment. 541 

Zuppinger's method, 542 
surface markings, 508 
shaft, 540 

complications. 549 
displacements, types of. 547 
etiology. 544 
prognosis, 551 
results. 568 
statistics, 568 
symptoms. 544 
treatment. 554. 581 
varieties. 544 

Balkan frame. 563 
Bradford frame. 550-585 
Buck's traction. 559 
Christen's suspension, 562 
gypsum dressing, 566 
non-operative, 567 
operative, 567 
reduction, 565 
Thomas knee-splint. 563 
vertical traction, 560 
tower end, 571 
varieties, 571 

supracondylar and intercondylar, 572 
complications, 573 
etiology, 5/2 
prognosis, 573 
symptoms. 572 
treatment, 574 
internal or external condyles, 575 
etiology, 575 
prognosis. 37s 
symptoms. 575 
treatment. 575 
epiphysis, separation of, 576 
complications, 577 
etiology, 576 
prognosis, 579 
symptoms, 576 
treatment, 577 
sprain-fractures, 578 
etiology. 579 
prognosis, 579 
symptoms. 579 
treatment. 579 
types, 578 



INDEX 



745 



Femur, neck of, fractures of, in childhood, 

512 
Femur, neck of, statistics on, in childhood, 

Haldenwang, quoted, 513 
Femur, fractures of, summary of treatment, 

58i 
Fibula, fractures of, 608 
Fibula, upper end, fractures of, 619 
etiology, 619 
symptoms, 619 
treatment, 619 

separation upper epiphysis, 621 
Fibula, shaft of, isolated fractures of, 622, 
640 
etiology, 640 
symptoms, 640 
treatment, 640 
Fissures, 9 
Fixation, direct, 100 

inlay bone graft, 118, 124, 126 
intramedullar bone graft, 108 
Lane's method, in 
Parham's band, 108 
Puth's method, 108 
Fracture-box in treatment of fractures of 

bones of leg, 631 
Fractures, articular, 12 
causes of, 2 
closed, 8, 97 
complete, 9 
compression, 11 
comminuted, 11 
definitions of, 1, 8 
double, 13 
green stick, 9 
impacted, 11 
in utero, 7 
intra partum, 7 
incomplete, 9 
joint, 12 
longitudinal, 10 
pathological, 5 
open, 8, 94, 96 
thrombosis in, 38 
gas bacillus in open, 96 
tetanus in open, 96 
sprain, 10 
varieties of, 8 
repair of, 25 
in articular, 26 
in closed fractures, 25 
in joint fractures, 26 
in open fractures, 26 
treatment of, 61, 89, 97, 705, 732 
symptomatology of, 15 
Fractures, complications, 29 
dressings, 61, 66, 67 
committee, British, 44, 128 
committee, American Surgical Associa- 
tion, 46, 128 
embolism, 38 
fat embolism, 37 
industrial, 88, 92, 94 

treatment of, 94 
infected and pulpefied, 88 
infected, 37, 38 
Fractures, closed operative treatment, 97 



Fractures of clavicle, 286, 708 
Fractures of costal cartilages, 285 
Functional impairment and loss of earning 

capacity, 61 
Functional results in relation to anatomical 

results, 65 
Functional treatment of fractures, 85 
Fragments, displacement of, 13 
etiology of displacement of, 15 
reduction of, 63 
retention of, 65 

Gangrene in fractures, 31 
General considerations, 1 
Gerrish, quoted ; rules of bony union of the 

diaphysis and epiphysis, 48 
Gibbs, quoted ; statistics on fractures of 

hyoid, 229 
Gunshot fractures, 91 

complications, 717, 723 

contamination in, 90, 719, 725, 734 

path of missile, 92 

displacement of fragments, 719 

epiphyseal, 726 

hemorrhage in, 723 

infected, 726 

of joints, 727 

prognosis, 728 

shell and shrapnel injuries, 718 

symptoms, 721, 723 

tetanus in, 724 

hemorrhage and shock, 40, 723 

treatment, 728 

Blake's opinions on treatment of, 725 
rules for treatment of, 732 
through and through wound, 90 
treatment of, rules for, 94 
Loewy, 94, 728 
operative, 90, 723 
types of fractures, 713 
Gunshot fractures of cranium, 717 
Gunshot fractures of cranium, 717 
lesion produced, 717 
skull, 717 
brain, 153, 157, 717 
Gurlt, quoted ; statistics on fractures of 
mandible, 211 
statistics on fractures of hyod, 229 

Hanging, judicial, type of fracture of verte- 
brae in, Wood- Jones, quoted, 245 
Hemothorax in rib fractures, 283 
Haenel (quoted by von Bergmann) ; results 

after malleolar fractures, 654 
Haldenwang, quoted ; statistics on fractures 
of the neck of the femur in childhood, 513 
Hawley's traction table, 103 
Heer, Anna, quoted ; cerebrospinal fluid in- 
basal fractures, 164 
Heer, Anna, quoted ; facial nerve inj ury in 

basal fractures, 167 
Hemorrhage, intracranial, in fractures of 
the skull, 167 
etiology, 167 
source, 167 

internal carotid, 167, 170 
intracranial sinuses, 167 



746 



INDEX 



Hemorrhage, middle meningeal, 167 
amount, 168 

blood-pressure changes, 169 
diagnosis, 169 
eye changes, 169 
hematomas, resulting, 168 
pulse changes, 169 
respiratory changes, 169 
mortality, operative, Bowen, quoted, 190 
Hemorrhage, middle meningeal, 167 
cause of death, 189 

eye, changes in, Bergmann, quoted, 169 
Kronlein's points of election for tre- 
phining, 168 
Hemorrhage, middle meningeal, mortality, 
operative, Bergmann, quoted, 189 
mortality, operative, Blake, quoted, 189 
operative mortality, Cushing, quoted, 

189 
operative mortality, Duchain, quoted, 

189 
in skull (basal) fractures, Dwight, 

quoted, 168 
treatment of, 190 
Hemorrhage, prearachnoid, 170 

in fractures of skull, treatment of, 188 
Hsematomas in middle meningeal hemor- 
rhage, Kronlein, quoted, 168 
Hernia of the lung in rib fractures, 282 
Hitzrot, results in fracture of neck of radius, 

416 
Hoffmann, quoted ; mortality in fractures of 
cartilage of larynx and trachea, 233 
statistics on fractures of cartilage of 
larynx and trachea, 233 
Holder, quoted; injury to optic foramen in 

basal fractures, 166 
Humerus, fractures of, 316 
anatomy, 316 
surface markings, 318 
upper end of humerus, 320 
varieties, 320 
head, 320 
etiology, 320 
symptoms, 320 
treatment, 320 
anatomical neck, 321 
etiology, 321 
symptoms, 321 
diagnosis, 322 
prognosis, 322 
treatment, 322 
tuberosities through, 323 
etiology, 323 
symptoms, 324 
treatment, 324 
tuberosity, isolated of greater, 325 
etiology, 325 
symptoms, 326 
diagnosis, 327 
treatment, 326 
tuberosity, isolated of lesser, 326 
symptoms, 327 
diagnosis, 327 
treatment, 327 
epiphysis, separation of upper, 327 
etiology, 329 



Humerus, fractures of, 

upper end of humerus, 320 
varieties, 320 

epiphysis, separation of upper, 

symptoms, 329 

diagnosis, 330 

treatment, 331 

after results, 332 
surgical neck, 332 

etiology, 333 

symptoms, 333 

diagnosis, 335 

complications, 335 

treatment, 337 

after results, 340 
shaft of humerus, 340 

etiology, 340 

symptoms, 342 

diagnosis, 342 

complications, 342 
musculospiral nerve injury, 343 
treatment, operative, 344 

treatment, 344 

after results, 348 

failure of union, 349 
pseudarthrosis, 349 
lower end of humerus, 350 

etiology, 350 _ 

forms found in childhood, 350 

forms found in adults, 351 

varieties, 350 
supracondylar, 352 

varieties, 352 

symptoms, 354 

diagnosis, 355 

mechanism fracure, 354 
diacondylar, 356 

mechanism of fracture, 357 

symptoms, 357 

diagnosis, 357 
intercondylar, T, Y , or atypical, 358 

etiology, 358 

symptoms, 359 

diagnosis, 360 
epiphysis, separation of lower, 360 

anatomy, 360 

etiology, 362 

symptoms, 362 

diagnosis, 363 
epicondyle, external, 364 

etiology, 364 

symptoms, 364 
condyle, external, 364 

etiology, 365 

symptoms, 366 
capitelhtm, 366 

etiology, 366 

symptoms, 367 
epicondyle, internal, 367 

etiology, 367 

symptoms, 368 

diagnosis, 368 
lower end of humerus, 350 
varieties, 350 

condyle, internal, 368 

statistics, 368 



INDEX 



747 



Humerus, fractures of, 

lower end of humerus, 350 
varieties. 350 
condyle, internal, 368 
etiology. 369 
symptoms, 369 
diagnosis, 369 
trochlea, 371 
etiology, 371 
symptoms, 371 
complications of fr. lower end of 
humerus, 371 
open fractures, 371 
Volkmann's ischsemic contrac- 
ture, 371 
blood-vessel injuries, 373 
nerve injuries, 373 
statistics, 374 
treatment, 374 
treatment, 374 
anaesthesia, 374 
ankylosis, 375 
reduction, 375 

hyperflexion and supination, 376 
Jones' position, 376 
cubitus varus, 383 
cubitus valgus, 383 
after results, 382 
treatment, operative, 384 
summary of treatment, 386 
Hyoid, bone, 229 
anatomy, 229 
etiology, 229 
statistics, 229 
symptoms, 229 
treatment, 230 
Hyoid, statistics on, Gibbs, quoted, 229 
Gurlt, quoted, 229 

Ilium, fractures of, 491 

Immelmann, quoted ; liability of individual 

bones to fracture, 1 
Immobilization temporary, of fragments, 62 
Impairment of motions in fractures of neck 

of femur, 519 
Incomplete union, 130 

causes and pathology, 130 

treatment, 132 
Indications for operative treatment, closed 

fractures, 97 
Industrial fractures, 713, 715 

from explosions, 715 

from railroad trains, 721 
Infection in fractures, 38, 719, 726, 734 

in closed fractures, 38 

in open treatment of closed fractures, 98 
Infolding fracture of lower end of radius, 

437 
Infection, 9, 38, 719, 726, 734 
Injury to important arteries and veins, 29 
Injuries to muscular system, 32 
Injury to neighboring joint, 35 
Injury to nerves, 31 
Injuries near shoulder-joint, differential 

diagnosis of, 335 
Internal carotid hemorrhage, 167, 170 
Intracranial sinuses hemorrhage, 186 



Intrapartum fractures, 7, 704 
Intrauterine fractures, 7, 704 
Inversion fracture of fifth metatarsal, 691 
Ischsemic muscular atrophy, 33, 371 
etiology, 34, 371 
symptoms, 34, 372 
treatment, 35, 373 

mechanical, after, 373 
operative, 35, 373 
preventive, 35 
Ischium, fractures of, 493 
Ischaemic myositis, 32, 33, 35, 371 

Jaw, lower, 210. See also Mandible 
Jensen, J., quoted; statistics on fractures of 

pelvis, 483 
Joints, injury to neighboring, in fractures, 35 
Jones, R., position in treatment of fractures 
of lower end of humerus, 376 
use of the Thomas knee splint in the 
treatment of fractures of the shaft 
of the femur, 563 
quoted ; use of Thomas knee splint in 
treatment of fractures of lower end 
of femur, 574 

Katzenelson, quoted ; anatomy of pelvic 

arches in relation to lines of fracture, 485 
Kocher, quoted ; classification of vertebral 
fractures, 244 
location of fractures of bodies of verte- 
brae, 244 
Kocher's classification of supracondylar 

fractures of humerus, 352 
Kohler, quoted; facial nerve injury in basal 

fractures, 167 
Kosmak's method of correction of depressed 

skull fractures, 707 
Kronlein's points of election for trephining 

in middle meningeal hemorrhage, 168 
Kronlein, quoted ; haematomas in middle 

meningeal hemorrhage, 168 

La Garde, quoted; gunshot injuries, 730 
Lane's plates in fractures, 11 1 

technic of application, 108 
Larynx and trachea, cartilages of, 229, 230 

anatomy, 230 

diagnosis, 232 

etiology, 232 

prognosis, 233 

surface markings, 231 

symptoms, 232 

treatment, 233 
Larynx and trachea, cartilages, mortality 
on, Hoffmann, quoted, 233 

statistics on, Hoffmann, quoted, 233 
Lente, quoted ; statistics on fracture of man- 
dible, 210 
Lerda and Quenu, quoted ; use of cocaine 
and novocaine in reduction of fractures, 
64 
Ligament of the patella, rupture of, 604 

etiology, 605 

prognosis, 605 

symptoms, 605 

treatment, 605 



48 



INDEX 



Liston or T-splint, 558 

Lothrop's, H. A., method of reduction in de- 
pressed malar fractures, 205 
Lowman's bone clamp, in fractures, 112 
Lumbar puncture in cranial fractures, 182 
Lucas-Championniere's method, 83 
Luxation, 1 
Lyle, modified Balkan frame, 94, 386, 542 

MacCormac, Sir W., quoted; cerebrospinal 

fluid, amount, in basal fractures, 164 
Makin's type of gunshot fractures, 714 
Malar bone, 202 
anatomy, 202 
complications, 204 
diagnosis, 204 

methods of examination, 202 
prognosis, 204 
surface markings, 202 
symptoms, 204 
treatment, 205 
varieties of fracture. 202 
Malgaigne, double vertical fracture of 

pelvis, 486 
Malleolar fractures, 644, 648, 661 
Mal-union, 130 

causes and pathology, 130 
treatment, 132 
Mandible, 210 
anatomy, 210 
complications, 218 
diagnosis, 220 
etiology, 211 
fractures of, special. 213 

see lower jaw, 210 
methods of examination, 215 
prognosis, 221 
results of, 228 
statistics, 210 

Gurlt, quoted, 211 
Lente, quoted, 210 
surface markings, 210 
symptoms, 217 
treatment, 221 

reduction of fragments, 222 
old fractures of, 228 
treatment by external splints, 222 
treatment by internal splints, 223 
summary of treatment, 22"] 
external dressings, 222 
interdental splints, 227 
mandibulomaxillary splints, 225 
suture, wire, 224 
results of, 211 
Martin, E. A., quoted; rapid fall of blood- 
pressure in application of traction, 121 
Masland's method of adjusting fragments, 

112 
Massage and passive motion, in the treat- 
ment of fractures, 83 
Matas' method of reduction of depressed 

' fractures of zygomatic arch, 206 
Maxilla inferior, see Mandible, 210 
Maxilla, superior, 206 
anatomy, 206 
complications, 208 



Maxilla, superior, 

diagnosis, 208 

pathology, 206 

prognosis, 208 

surface markings, 202 

symptoms, 208 

treatment, 209 

varieties, 207 
Medical, British Association Committee, 44 
Metacarpal bones, 466 

anatomy, 467 

diagnosis, 469 

etiology, 467 

results, 473 

surface markings, 467 

symptoms, 467 

first metacarpal, 467, 469 
second to fifth metacarpals, 469 

treatment, 469 
Metatarsal bones, 688 

anatomy, 688 

etiology, 688 

prognosis, 671 

statistics, 688 

surface markings, 688 

symptoms, 688 

treatment, 692 
Middle meningeal, hemorrhage, treatment 

of, 190 
Mobilization in treatment of fractures, 83 
Muhlenberg and Berenger-Feraud, quoted; 
pseudarthosis in fractures of mandible, 
221 
Muscular relaxation in fractures of neck of 

femur, 519 
Muscular system, injury to, in fractures, 32 
Myositis, ischemic, 33, 35, S73 

treatment of, 3^3 

Nail extension in fractures, 79 

Steinmann's, 79 
Nasal bones, 194 
anatomy, 194 
complications, 199 
diagnosis, 198 

displacement of fragments, 197 
etiology, 194 

methods of examination, 197 
prognosis, 199 
symptoms, 198 
treatment, 199 

old unreduced fractures. 201 
recent fractures, 194 
varieties. 195 
Nerve (abducens). injury in skull (basal) 

fractures, Schroder, quoted, 167 
Nerves, cranial, involved, in basal fractures, 
166 
anterior fossa, 166 
middle fossa, 167 
posterior fossa, 167 
Nerve (facial), injury in skull (basal) frac- 
tures, Anna Heer, quoted, 167 
Nerve (facial), injury, in skull (basal) 
fractures, Kohler, quoted, 167 



INDEX 



749 



Nerve, hypoglossal, injury in skull (basal) 

fractures, Stierlein, quoted, 167 
Nerves, hypoglossal and spinal accessory, 

injury to, in basal skull fractures, v. Berg- 

mann, quoted, 167 
Nerve, median, injury of. in fractures of 

lower end of humerus, Ashhurst, A. P. C, 

quoted, 374 
Nerve, musculospiral, injury, in fractures 

of lower end of humerus, Coenen, quoted, 

374 
Nerve, musculospiral, injury, in fractures ot 

shaft of humerus, 342 
Nerve, musculospiral paralysis, 343 
primary paralysis, 343 
intermediate paralysis, 343 
secondary paralysis, 343 
reactions of degeneration, 344^ 
treatment, 344 
operative, 344 
Nerve (optic), injury, in basal skull frac- 
tures, Cullen, quoted, 166 
Nerve, popliteal, injury to, in fractures of 

lower end of femur, 573 
Nerves, injury to, in fractures, 31 
Nerve injuries complicating fractures, 31 
musculospiral, 31 
radial, 31 
ulnar, 31 
Nerve injury complicating fractures of the 
lower end of humerus, 374 
statistics, 374 
treatment, 374 
Nerve injury, in fractures of lower end of 
the humerus, Destot, Vignard and Bar- 
latier, quoted, 374 
Nerve injury, in fractures of lower end of 
the humerus, Broca and Mouchet, quoted, 

374 . . 

Nerve, injury to, in fracture of pelvis, 501 
Nichols, E. H., quoted ; hemorrhage from 

middle meningeal in skull fractures, 169 
Non-union, 2.J, 130 

in tractures of mandible, 228 
Norris, quoted ; non-union in fractures of 

mandible, 221 

Obstetric fractures, 704 
bones of arm, 712 
cranium, 712 
clavicle, 704 
etiology of, 704 
femur, 709 

treatment of, 712 
humerus, 706 
Oedem in fractures, 17 
Open (compound) fractures, 88 
debridement in, 90 

bone graft in, 94 

Carrel-Dakin instillation in, 91 

neutral hypochlorite solution in, 91 
treatment of, 88, 89 
types of, 88 

conservative treatment, 88 
wisdom of primary suture or plating 

of fragments. 90 



Operative procedures for fractures of vault 

of skull, 182 
Operative treatment in closed fractures, 97 

classification of cases for, 102 
Optic foramen, injury to, in skull (basal) 

fractures, Holder, quoted, 166 
Ossification of bones, 40 
Os calcis, 698 
Os intercuneiforme, 698 
Os intermetatarsale, 698, 699 
Os tibiale enternum, 698, 699 
Os trigonum, 698 
Os peroneale, 698, 699 
Os Vesalii, 698, 699 
Other sesamoid bones than patella, 697 

Pain and tenderness in fractures, 18 
Paralysis, Brown-Sequard, in vertebral 

fractures, 262 
Paralysis, motor, in vertebral fractures, 250 

sensory, in vertebral fractures, 252 
Parham's band for direct fixation, 108 
Passive motion, in fractures about elbow, 

379 
Patella, 587 

anatomy, 587 
diagnosis, 592 
diagnosis, differential, 593 
etiology, 587 
prognosis, 593 
statistics, 587 
surface markings, 587 
- symptoms, 590 
treatment, 594 

non-operative, 594, 596 
operative, 595-597, 598 
results, 600 
results, end, 601 

Malgaigne's method, 595, 605 
purse-string method, 597 
Wyeth's method for, 600 
summary of treatment, 605 
varieties and mechanism, 588 

rupture of quadriceps, extensor ten- 
don of, 603 
rupture of patella ligament, 604 
Patella, ligament of, rupture of, 604 
etiology, 604 
prognosis, 604 
symptoms, 604 
treatment, 605 
Patella, refracture of, 601 
Patella, results of operative treatment, 

Delatour, quoted, 601 
Patella, results after treatment, Quinby, 

W. C, quoted, 600 
Patella, old fracture of, 602 
Pathologic fractures, 5 
aneurysms, 6 
inflammatory processes, 5 
new growths, 7 

resulting from a general disease. 6 
Pelvic arches, anatomy of in relation to lines 

of fracture. Katzenelson, quoted. 485 
Pelvis, 481 

anatomy, 481 

character of fracture. 485 



750 



INDEX 



Pelvis, 

complications, 498 

injury to bladder and urethra, 500 
injury to blood-vessels, 501 
injury to nerves, 500 
etiology, 484 
prognosis, 501 
statistics, 483 
surface markings, 482 
symptoms, 494 
treatment, 501 

of the complications, 503 
of the fracture, 485 
varieties of fracture, 485 
Phalanges of foot, 688-696 
etiology, 696 
symptoms, 696 
treatment, 696 
Phalanges of hand, 475 
anatomy, 475 
diagnosis, 479 
etiology, 477 
symptoms, 478 
treatment, 479 
results, 480 
Phelps, quoted ; cerebrospinal fluid in basal 

fractures, 164 
Pia-arachnoid hemorrhage, in fractures of 

skull, treatment of, 190 
Plagemann, quoted ; liability of individual 

bones to fracture, 1 
Pneumothorax, in rib fractures, 283 
Posture in bed, in vertebral fractures, 249 
Postural treatment, 83 

by method of Lucas- Championniere, 83 
Prognosis in fractures, 42 
Pott's fracture, 644 
Prearachnoid hemorrhage, 170 
Priapism, in vertebral fractures, 258 
Prognosis, general, in fractures, 42 
Pseudarthrosis in fractures of mandible, 
Muhlenberg and Berenger-Feraud, 
quoted, 221 
in fractures of neck of femur, 525 
following fractures of shaft of 
humerus, 345 
Pulmonic complications in fractures, 41 
Pubes, fracture of, 485 

separation of symphysis, 486 
separation of sacro-iliac synchondrosis, 

487 
fracture of ramus of, 486 
Puth's method of direct fixation, 108 



Quadriceps extensor tendon of patella, rup- 
ture of, 603 
etiology, 603 
prognosis, 604 
symptoms, 604 
treatment, 605 
Quinby, W. C, quoted ; operative and non- 
operative results in th 1 treatment of frac- 
tures of the patella, 600 



Radiographic examination as a guide in 
treatment, 61 
epiphyseal separations, 58 
Radius and ulna, 387 
anatomy, 387 
surface markings, 389 
upper end, 390 

radius and ulna, combined, 390 
complications, 394 
diagnosis, 394 
displacements, 392 
etiology, 390 
results, 398 
symptoms, 393 
treatment, 394 

non-operative, 394 
operative, 397 
ulna, isolated fractures of, 399 
olecranon process, 399 
displacements, 399 
etiology, 399 
results, 404 
symptoms, 400 
treatment, 402 
non-operative, 404 
operative, 402 
coronoid process, 405 
displacements, 406 
etiology, 405 
mechanism, 405 
results, 407 
symptoms, 406 
treatment, 407 
styloid process, 411 
separation, epiphysis lower end, 412 
ulna, shaft of, 408 
displacements, 409 
etiology, 408 
symptoms, 409 
treatment, 410 
radius, isolated fractures of, 413 
head of radius, 413 
displacements, 417 
etiology, 414 
results, 416 
symptoms, 414 
treatment, 415 
non-operative, 415 
operative, 416 
epiphysis, separation of upper, 416 
displacements, 418 
results, 419 
symptoms, 418 
treatment, 418 
epiphysis, fracture of upper, 417 
neck of radius, 417 
displacements, 418 
etiology, 417 
results, 418 
symptoms, 418 
treatment, 418 
radius, shaft of, isolated, 419 
displacement, 420 
etiology, 420 
symptoms, 421 
treatment, 421 



INDEX 



751 



Radius and ulna, 

radius, lower end, 422 
Colles's fracture, 423 
diagnosis, 448 
diagnosis, differential, 448 
etiology, 424 
impaction, 442 
results, 458 
symptoms, 438 

Smith's fracture, 431, 438, 458 
treatment, 449 
anaesthesia, 458 
reduction, 449 
retention, 452 
splints, 453 

after treatment, 457, 458 
summary of treatment, 460 
varieties of fracture, 425 
with anterior displacement, 43 1 * 
438, 458 
Radius, head of, results in fracture of, 415 
neck of, results in fracture of, Hitzrot, 
quoted, 416 
Rawling, quoted ; cerebrospinal fluid in basal 
fractures, 165 
deductions in head injuries from tem- 
perature changes, 172 
escape of brain tissue in basal fractures, 

165 
eye changes in middle meningeal hemor- 
rhage, 169 
hemorrhage from middle meningeal in 

skull fractures, 168 
mortality of skull fractures, 163 
mortality of skull fractures in relation 
to temperature changes, 172 
Rawling's rules as to the probable line of 

transbasal fracture, 159 
Reduction of fragments, 63 
anaesthesia, 63 
obstacles to reduction, 64 
methods of reduction, 65 
non-operative, 65 
operative, 65 
time of, 64 
Reflexes, disturbance of, governing bladder 
and rectum, in vertebral fractures, 256 
in vertebral fractures, 255 
Reid's base line, 143 
Relationship to age, sex, and season, 1 
Repair of fractures, 25 

in recent closed fractures, 25 
in recent open fractures, 26 
in recent closed fractures treated by 
aseptic operation, 27 
Results in fractures of lower end of 
humerus, Ashhurst, A P. C, quoted, 383 
Results in treatment of fractures, British 
Medical Association, fracture committee, 
quoted, 102 
Results in treatment of fractures of shaft 
of the femur, British Medical Associa- 
tion, fracture committee, quoted, 568 
Results in treatment of fractures of tibia 
and fibula, British Medical Association, 
fracture committee, quoted, 637 



Retention of fragments, 65 
temporary dressings, 66 
permanent dressings, 66 
Retentive dressings in fractures, 66 
fixation dressings, 66 
gypsum encasements, 72 
plaster of Paris, 72 
fixation and traction dressings, 67, 77 
splints, 66 
splints, moulded, 69 
traction dressings, 67 
Retentive dressings, rules to be observed in 

the application of, 67 
Reversed Barton's fracture, 435 
Reversed Colles's fracture, 429, 431, 438, 458 
Ribs and costal cartilages, 272, 276 
anatomy, 276 
statistics, 278 
surface markings, 277 
ribs, 272, 276 
anatomy, 276 
complications, 281 
intrathoracic, 281 
intraabdominal, 283 
diagnosis, 283 
etiology, 278 
pathology, 278 
prognosis, 283 
surface markings, 277 
symptoms, 280 
treatment, 283 
varieties, 279 
costal cartilages, 285 
Rontgen rays in diagnosis of fractures, 20 

in diagnosis and treatment, 97 
Roser-Nelaton line in determining frac- 
tures of the neck of the femur, 521 
Ruth-Maxwell method of treatment of 
fractures of neck of femur, 528 

Sacrum, 491 

Sacro-iliac synchondrosis, separation of, 487 
Saw, Albee's, 125 
Masland, 125 
Sayre, dressing, 298 
Scaphoid, carpal, fractures of, 464 
Scaphoid, tarsal, 684 
etiology, 684 
prognosis, 687 
symptoms, 684 
treatment, 687 
Scapula, 303 

anatomy, 303 
surface markings, 304 
summary of treatment, 315 
body of scapula, 304 
etiology, 304 
prognosis, 305 
symptoms, 305 
treatment, 305 
varieties, 305 
superior angle of scapula, 306 
etiology, 306 
symptoms, 306 
treatment, 306 
varieties, 306 



v52 



INDEX 



Scapula, 

inferior angle of scapula, 306 
etiology, 306 
symptoms, 306 
treatment, 306 
spine of scapula, 307 
symptoms, 307 
treatment, 307 
varieties, 307 
acromion process of scapula, 307 
prognosis, 308 
symptoms, 308 
treatment, 309 
varieties, 308 
neck of scapula, 310 
diagnosis, 312 
etiology, 311 
symptoms, 311 
treatment, 313 
varieties, 310 
coracoid process of scapula, 313 
etiology, 313 
symptoms, 314 
treatment, 314 
varieties, 314 
rim of glenoid cavity of scapula, 314 
etiology, 314 
symptoms, 315 
treatment, 315 
varieties, 315 
Schroder, quoted; abducens nerve injury 

in basal fracture, 167 
Semilunar, fracture of, 465 
Sesamoid bones, 697 

see fractures of patella 
Sesamoid bones of phalanges, 699 
Sesamoid, anatomy, 697 
etiology, 700 
statistics, 699 
symptoms, 701 
treatment, 703 
varieties, 697-699 
Sherman's plates in fractures, 123 

screws, 123 
Shepherd's fracture, 698 
Shock and hemorrhage in fractures, 40 
Shortening in fractures of the neck of the 
femur, 521 
methods of determining shortening, 521 
Silver-fork deformity in fractures at lower 

end of radius, 441 
Skull, see Cranium 
Smith's fracture, 431, 438, 458 
Soft parts, injury to, overlying, in frac- 
tures, 29 
Spinal cord lesions, location of injury, 

Cushing, quoted, 254 
Spinal cord segments and their nerve roots, 
relationship of, to the bodies and spines 
of the vertebrae, Dejerine, quoted, 248, 251 
Sprain-fracture, 1 

Sprain-fracture, lower end of radius, 437 
Splints, 68 
angle, 224 
Hammond, 224 
Gunning, 224 



Splints, bracketed, 91 

Nathan Smith, 80 

Thomas, 81 
Splints, Cabot's posterior wire, use of, in 

fractures of bones of leg, 632 
Splints, finger, 480 
Splints, Levis metal chin, for mandible, 222 

Angle, for mandible, 224 

Blair, 223 

Cryer, for mandible, 225 

Gunning, for mandible fractures, 223, 
227 

Hammond, for mandible, 224 

Hern, for mandible fractures, 223 

interdental splints, 224 

Martin, 224 
Splints, metal, 69 

aluminum, 69 

wire, 69 

wire gauze, 69 

tin, perforated, 69 

zinc, perforated, 69 
Splints, moulded, 69 

celluloid, 69 

felt, poroplastic, 69 

leather, 69 
Splints, nasal, 201 
Splints, plaster-of-Paris, 72 

advantages of, 76 

" casts," 72 

encasements, 72 

for fracture of clavicle, 70 

for fractures of upper extremity, 71 

for fractures of lower extremity, 74, 76 

for shoulder cap, 70 

method of using, 76 

moulded " contour," 69, 72 

use in open fractures, 76 

Velpeau dressing, 70 
Splints, pillow at side, in treatment of frac- 
tures of bones of leg, 630 
Splints, types of, 68 
Splints, use of gypsum case in treatment of 

fractures of bones of leg, 630 
Splints, wood, 68 
Sprain, definition, 1 
Sprain-fracture, 1 

of lower end of radius, 437 
Statistics, Duval's in gunshot fractures, 91 
Steinmann's method of nail extension, 80 

modifications of method, 81 

value of method, 81 

disadvantages of method, 80 

technic of applications, 80 
Sternum, 272 

anatomy, 272 

complications, 274 

diagnosis, 274 

etiology, 273 

prognosis, 275 

statistics, 273 

surface markings, 272 

symptoms, 274 

treatment, 275 

varieties, 273 
Stierlein, quoted; hypoglossal nerve injury 
in basal fractures, 167 



INDEX 



753 



Suspension, balanced, 94, 386, 542 
Symptomatology, general, 15 

constitutional, 18, 40 

objective, 16 

subjective, 16 

Tarsal bones. 665 
anatomy, 665 
statistics, 671 
Tarsal bones, surface markings, 666 
astragalus, 667 
etiology, 618 
prognosis, 669 
results, 671 
symptoms, 669 
treatment, 670 
varieties, 668 
calcancum, 671 
etiology, 672 
prognosis, 682 
statistics, 678 
symptoms, 680 
treatment, 682 
non-operative, 682 
operative, 683 
varieties, 672 
Tarsal scaphoid, 684 
etiology, 684 
prognosis, 687 
symptoms, 684 
treatment, 687 
Technic of operation in closed fractures 

I0 5 
Temperature changes in head injuries, 172 

Tendon of quadriceps extensor, rupture of 
603 
etiology, 603 
prognosis, 603 
symptoms, 603 
treatment, 604 
Thrombosis and embolism, in fractures, 38 
Thomas, T. T., quoted ; results in fractures 

of head of radius, 416 
Thumb, stave of, 469 
Tibia, avulsion of tubercle, 619 
anatomy, 619 
etiology, 619 
symptoms, 620 
treatment, 621 
Tibia and fibula, fractures of, 608 
anatomy, 600 
surface markings, 608 
Tibia and Fibula : 

lower end, fibular malleolus, isolated, 
661 
etiology, 662 
prognosis, 662 
symptoms, 662 
treatment, 662 
fibular malleolus and posterior articu- 
lar edge of tibia, 648 
etiology, 648 
mechanism, 648 
prognosis, 648 
symptoms, 648 
treatment, 650 



Tibia and Fibula : 
lower end, 
fibula and external articular edge of 
tibia, 657 

etiology, 657 

mechanism, 657 

prognosis, 657 

symptoms, 657 

treatment, 657 
lower end, internal malleolus isolated, 
661 

etiology, 661 

prognosis, 661 

symptoms, 661 

treatment, 661 
malleolar, Pott's, 644 

displacements, 648 

etiology, 647 

mechanism, 647 

prognosis, 652 

results, 654 

symptoms, 650 

treatment, 653 
Pott's inverted, 65 

etiology, 657 

mechanism, 659 

prognosis, 660 

symptoms, 659 

treatment, 660 
separation of lower epiphysis, 642 
supramalleolar, 641 

diagnosis, 641 

etiology, 641 

prognosis, 641 

statistics, 641 

symptoms, 641 

treatment, 642 
tibia, anterior articular edge, 664 

etiology, 664 

symptoms, 664 

treatment, 664 
shaft, 622 

complications, 627 
displacements, 623 
etiology, 622 
prognosis, 627 
results, 637 
statistics, 639 
symptoms, 623 
treatment, 629 

of infected fractures, 635 

non-operative, 630 

operative, 632 

open fractures, 635 
varieties of shaft, 622 

deformed union, 664 
upper end, 609 
complications, 617 
etiology, 609 
prognosis, 617 
symptoms, 616 

adults, 616 

children, 616 
Tibia, upper epiphysis, separation of, 620 
treatment, 617 
varieties, 609 



754 



IXDEX 



Tibia, isolated upper end, 617 
treatment, summary of, 664 
lower end, 664 
shaft, 664 
upper end, 664 
Tibia, shaft of, isolated of, 639 
etiology, 639 
statistics, 639 
symptoms, 639 
treatment, 640 
Time of reduction, 64 
Traction, longitudinal in marked abduction 

in fractures of neck of femur, 527 
Traction, 77, see Extension 
Bryant's, 78 
Zuppinger's. 82 
Transportation of patients, 62 
Traumatic asphyxia in rib fractures, 282 
Traumatic delirium, 40 
Treatment, ambulatory, of fractures, 86 
functional, of fractures. 85 
general considerations, 61 
balanced - suspension and traction 

(Lyle), 584 
gunshot fractures, 94, 719, 725, 728, 732 
industrial fractures. 94 
infected fractures, 88 
open and infected fractures, 88, 94, 732 
operative, cases designated for, 88 
Albee's inlay bone graft, 124 
instruments used, 125 
technic, 126 
American Surgical Association, 

quoted ;" conclusions in the, 129 
cause of failures of, quoted from 
American Surgical Association, 
fracture committee, quoted, 128 
cause of failures of, quoted from 
fracture committee of the B. M. A., 
128 
Treatment, operative, conclusions of Ameri- 
can Surgical Association, quoted, 
129 
contraindications to, 99 
importance of external splinting, 123 
indications that call for, 100 
of closed fractures, 97, 100 
time of operation, 102 

in recent closed fractures, 102 

in fractures impossible of retention, 

102 
in non-union, deficient union, or 
faulty union, 104 
mobilization of Lucas-Champion- 

niere, 83 
postural treatment, 83 
technic of operation in closed frac- 
tures, 105 
repair without internal fixation. 106 
repair with internal fixation. 107 
Trophic and vasomotor disturbances in 
vertebral fractures, 258 

Ulna fractures, 387, 390, 399 
Union, delayed. 27. 130 

vicious, 27, 29, 130 

non-, 27, 130 



Uterine fractures, 7 

Varieties of fractures, 8 

in relation to condition of surrounding 

soft parts, 8 
in relation to degree, 9 
in relation to direction and character of 

lines of fracture, 10 
in relation to epiphyseal lines, 12 
in relation to neighboring joints, 12 
in relation to number of fragments, 13 
in relation to position of the fracture, 12 
Velpeau dressing for fractures of clavicle, 

70 
Venesection, in fractures of skull, 181 
Vertebrae, 234 
anatomy, 234 
diagnosis, 264 
etiology, 237 

fracture, dislocation of, 243 
prognosis, 265 
surface markings, 236 
varieties, 238 
Vertebrae, symptoms, 246 

those associated with the fracture, 

246 
those due to injury to spinal cord and 

nerve roots, 249 
paralysis, motor, 250 
paralysis, sensory, 252 
reflex disturbances, 255 
trophic and vasomotor disturbances, 

lesions of various segments, 259 
hemorrhage in dura and spinal cord. 
264 
treatment, 266, 267 
non-operative, 266 

in absence of injurv to spinal cord, 

266 
in presence of injurv to spinal cord, 

266 
care of bladder and rectum, 267 
operative, 267 

indications, contraindications, 267 
laminectomy, 267 
post-operative, 271 
Vertebrae, fractures, disturbances of re- 
flexes governing bladder and rectum, 256 
Vicious union, 28, 130 
Volkmann's contracture, 33, 35, 371 
Volkmann's ischaemic contracture, 33, 35, 

371 
etiology. 34. 371 
pathology, 33, 371 
symptoms, 34, 372 
treatment. 35, 373 
Vogt's rule, for trephining points in middle 
meningeal hemorrhage, 188 

Wagner, quoted ; mortality of skull frac- 
tures, 178 

War fractures, 713 

Weight-bearing after fractures of tibia and 
fibula, 87 

Wendt. quoted; statistics on supracondylar 
fractures of humerus, 352 



INDEX 



755 



Whitman's method of abduction in the treat- 
ment of separation of the upper femoral 
epiphysis, 532 
Whitman's method of abduction in fracture 
of neck of femur, 534 
principles and mode of application, 
534 
Wiesmann, quoted; operative mortality in 

middle meningeal hemorrhage, 189 
Wood-Jones, quoted; type of fractures of 
vertebras in judicial hanging, 245 



Wright. Almroth, quoted ; use of hypertonic 
sodium citrate solution, in gunshot in- 
juries, 733 

Wrist-drop, musculospiral nerve injury 
complicating fracture of shaft of 
humerus, 344 

Wyeih's method of suture for fracture of 
patella, 600 

Zuppinger's apparatus in the treatment of 

fractures, 82 
Zygomatic bone, see malar bone, 202 



